"PRACTICE MANAGEMENT The Patient-Centered Medical Homeand Meaningful Use: A Challengefor Better Care † Janis Coffn, DO, FAAFP, FACMPE,* Carla Duffe, DNP, MHSA, RN, ‡ and Megan Furno, RHIA *Georgia Regents University, MCG/ This article discusses and illustrates the alignment between the NationalFamily Medicine, 1120 15th Street,Committee for Quality Assurance’s Patient-Centered Medical Home and HB 2050, Augusta, GA 30912; phone:706-721-2369; e-mail: [email protected] Use. In addition to the various overlaps, there is also signifcant dis- †Georgia Regents University, MCG/ Family Medicine, Augusta, Georgia.cussion about Patient-Centered Medical Home and Meaningful Use as well as‡Georgia Regents University, MCG/ Family Medicine, Augusta, Georgia. their distinct requirements. With impending deadlines for Meaningful Use andCopyright © 2014 bypotential penalties being imposed, this article provides a layout of dates, stages, Greenbranch Publishing LLC. and incentive payments and penalties for Meaningful Use, and discusses howobtaining Patient-Centered Medical Home recognition could be benefcial toachieving Meaningful Use. KEY WORDS: Meaningful Use; Patient-Centered Medical Home; requirements;incentives; Stage 1; Stage 2. n 2001, the Institute of Medicine publishedCrossing the 77 A coordinated care system is one that incorporates allQuality Chasm, which was ofered as a guide for patient components of the complex healthcare system. Medicalto clinician relationships and a redesign for the Ameri - practices participate in quality and safetytraining andIcan healthcare system. Patient-centeredness was one of evaluation, during which the practices voluntarily en- six healthcare quality aims. Since then, patient centered- gage in quality improvement activities to ensure patientsafety is always being met. ness has been at the forefront of healthcare reform for both77 Enhanced access to care through open-access schedul- Patient-Centered Medical Home (PCMH) and Meaningfuling and communication mechanisms allows patientsUse (MU). Patient centeredness “encompasses qualities ofto get same-day appointments and communicate withcompassion, empathy, and responsiveness to the needs,their care team via e-mail. values, and expressed preferences of the individual p- a 1 77 A payment model that is refective of the true value oftient.” Te patient-centered approach includes viewingcoordinated care and innovation suggests substantialthe patient as a unique person, rather than focusing onchanges to the payment structure providing reim- the illness, which builds a benefcial alliance based on thebursement that acknowledges the value of this patient- patient’s and the provider’s perspectives. 2 focused care model. According to The Joint Principles of the Patient- Centered Medical Home, the characteristics of a PCMHA PCMH requires behavioral changes across theshould include the following concepts: practice, from front desk personnel to providers. Staff77 A personal physician acts as the leader of the care teammembers must function as a “team” to provide quality,and coordinates all aspects of patient care, includingcomprehensive care that is efcient, cost efective, andreferrals to specialists, acute care, preventive services,accessible. and care through all stages of life. The designation of a PCMH did not initially bring77 A physician-directed medical practice has a coordinated incentives and thus has not been adopted by all pri- team of professionals who work together to provide this mary care clinics. Te Centers for Medicare & Medicaidhigher level of care for their patients, meeting the princi - Services (CMS) has developed MU to entice providersple of comprehensive care or whole-personorientation. to adopt a certified electronic health record (EHR) by www.greenbranch.com | 800-933-3711 331| 332 Medical Practice ManagementMarch/April 2014adding incentives and then penalties. These incentives provider must bill Medicare or Medicaid a minimum ofwill infuence most hospitals and clinics to adopt certifed $24,000. No payments will be offered to physicians who3 EHRs to increase the safety and quality of care and reduce frst become eligible after 2014. healthcare expenditures. CMS is using the “carrot and Penalties will begin in 2015 for EPs who do not adoptstick” method; incentives began in 2011 with amounts as systems that allow them to demonstrate MU of EHRs andhigh as $44,000 for the Medicare program and $63,750 for systems. EPs who do not demonstrate MU in 2014 will bethe Medicaid program. Eligible professionals (EPs) can penalized by a 1% decrease in their 2015 Medicare fee sched - participate in either the Medicare or Medicaid route for ules. There is to be an additional decrease by additionalincentives. Unlike hospitals, an EP can participate in only percentage points in 2016 and 2017. As of June 2012, if totalone program. Before 2015, an EP may switch between the adoption is below 75% in 2018, the fee schedule could be re - 3programs one time after the incentive payment is initiated. duced to 95%. Tere are currently no payment adjustmentsTere are diferences in the two incentive programs. Te or penalties for Medicaid providers who fail to demonstrate4Medicare program includes “nonhospital-based” providers MU. State Medicaid guidelines should be referenced be - such as physicians and dentists (MD, DO, DOS, DDM), po- cause Medicaid programs are run by individual states. diatrists, optometrists, and chiropractors. Medicare ofers Stage 1 of MU has already begun, and Stage 2 will startup to $44,000 in incentives, but the EP must demonstrate this year. Te Ofce of the National Coordinator for HealthMU in every year and must have participated by 2012 to Information Technology (ONC) has said all along thatreceive the maximum incentive. The Medicaid program for the implementation of health information technologyincludes nonhospital-based physicians to include nurse (HIT) to be successful, there needs to be concurrent trans - practitioners, certifed nurse midwives, dentists, or physi- formation at the practice level, particularly with opportuni - 2 cian assistants with greater than 30% Medicaid volume or ties specifcally related to HIT. 20% for pediatricians. Tis program includes up to $63,570 EPs and hospitals that began their participation inin incentives. Te EP can register once the state program Stage 1 MU in 2011 have an additional year to advance tohas been approved, and the EP can qualify by implement - Stage 2 MU. Additionally, these EPs and hospitals have twoing a certifed EHR in the frst year but must demonstrate full years to manage both the technological and adminis - MU in subsequent years. EPs must participate by 2016 to trative requirements to demonstrate MU in Stage 2 withoutreceive the maximum incentive. Terefore, large groups straining themselves to prepare for Stage 3. Tis extensionmay choose to have certain EPs participate in the Medicare in timing should mean that Stage 3 MU begins in 2017, ac- program and designate other providers to participate in the cording to the revised plan. 3 Medicaid program. Te two-year window for Stages 2 and 3 also applies toTable 1 illustrates how the Medicare and Medicaid EPs in the EHR Incentive Program for Medicaid and Medi - programs are similar in many ways, but there are some care. Stage 1 still remains just one year to adopt, imple- 5 important diferences between them. ment, or upgrade to a certifed EHR system. Practices with multiple physicians will be eligible toreceive incentive payments for each provider. PaymentsOBJECTIVES will be based on 75% of the correlating year’s Medicareand Medicaid charges. Therefore, in order to qualify for Te total number of objectives for EPs and hospitals hasthe maximum payment of $18,000 in the first year, each not changed. However, the makeup of those measures has.Table 1. Medicare and Medicaid EHR Incentive Programs Medicare EHR Incentive Program Medicaid EHR Incentive Program Run by CMS Run by your state Medicaid agency Maximum incentive amount is $44,000 Maximum incentive amount is $63,750 Payments over 5 consecutive years Payments over 6 years, do not have to be consecutive Payment adjustments will begin in 2015 for providers who are No Medicaid payment adjustments eligible but decide not to participate Providers must demonstrate MU every year to receive In the frst year, providers can receive an incentive payment forincentive payments adopting, implementing, or upgrading EHR technology Providers must demonstrate MU in the remaining years to receiveincentive payments CMS, Centers for Medicare & Medicaid Services; EHR, electronic health record; MU, Meaningful Use. Source: Centers for Medicare & Medicaid Services; www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index. html?redirect=/EHRIncentivePrograms.www.greenbranch.com| 800-933-3711 |Coffn, Duffe, and Furno PCMH and Meaningful Use 333 EPs must report 17 core objectives and 3 of 6 menu objec - 16. Capability to submit electronic data to immunizationregistries or immunization information systems excepttives in Stage 2 as compared to 15 core objectives and 5 ofwhere prohibited, and in accordance with applicable10 menu objectives in Stage 1. Eligible hospitals, includinglaw and practice. critical access hospitals, must report on 16 core objectives17. Use secure electronic messaging to communicate withand 3 of 6 menu objectives as compared to 14 core objec - patients on relevant health information. tives and 5 of 10 menu objectives. Menu Objectives Core Objectives 1. Capability to submit electronic syndromic surveillance1. Use computerized provider order entry (CPOE) fordata to public health agencies except where prohibited,medication, laboratory, and radiology orders directlyand in accordance with applicable law and practice. entered by any licensed healthcare professional who2. Record electronic notes in patient records. can enter orders into the medical record per state, lo- 3. Imaging results consisting of the image itself and anycal, and professional guidelines. explanation or other accompanying information are ac - 2. Generate and transmit permissible prescriptions elec- cessible through Certifed EHR Technology. tronically (eRx). 4. Record patient family health historyas structured data. 3. Record the followingdemographics: preferred lan - 5. Capability to identify and report cancer casesto a publicguage, sex, race, ethnicity, date of birth. health central cancer registry, except where prohibited,4. Record and chart changes in the followingvital signs:and in accordance with applicable law and practice. height/length and weight (no age limit); blood pres- 6. Capability to identify and report specifc casesto a spe- sure (ages 3 and over); calculate and display body masscialized registry (other than a cancer registry), exceptindex (BMI); and plot and display growth charts forwhere prohibited, and in accordance with applicablepatients 0 to 20 years, including BMI. law and practice. 5. Record smoking status for patients 13 years old orView or download all of the EP Stage 2 Core and Menuolder. Objectives at: www.cms.gov/regulations-and-guidance/ 6. Use clinical decision support to improve performancelegislation/ehrincentiveprograms/stage_2.html. A com- on high-priority health conditions. parison of Stage 1 vs. Stage 2 MU for EPs can be viewed or7. Provide patients the ability to view online, download,downloaded at: www.cms.gov/Regulations-and-Guidance/and transmit their health information within four busi - Legislation/EHRIncentivePrograms/Downloads/Stage1ness days of the information being available to the EP. vsStage2CompTablesforEP.pdf . 8. Provide clinical summaries for patients for each ofcePresently, the payment system in the United Statesvisit. is based on fee for service, not pay for performance or9. Protect electronic health informationcreated or main- shared incentive plans for quality of care. In the future,tained by the Certifed EHR Technology through thereimbursements will be based on quality of care andimplementation of appropriate technical capabilities. bonus for pay for performance. Tere will also be shared10. Incorporate clinical lab-test results into Certifed EHRincentives for having a working population-based healthTechnology as structured data. 5 system in place. 11. Generate lists of patientsby specifc conditions to useMeasuring performance is an all-or-nothing approach.for quality improvement, reduction of disparities, re - EPs and hospitals must report on all core measures andsearch, or outreach. meet any stated targets in order to achieve MU. Measures12. Use clinically relevant information to identify patientsmust be reported on all patients, not just Medicare andwho should receive reminders for preventive/follow- Medicaid patients. up care, and send these patients the reminders, perFor practices to be successful in PCMH and MUpatient preference. transformation, leadership must be committed to notify - 13. Use clinically relevant information from Certifieding providers of their progress. In the Family MedicineEHR Technology to identifypatient-specifc educationCenter at Georgia Regents University, we developed aresources, and provide those resources to the patient. PCMH and MU task force that sends notifcation to the14. The EP who receives a patient from another settingindividual providers regarding progress. Tis has allowedof care or provider of care or believes an encounteran institution that is known for tertiary and quaternaryis relevant should performmedication reconciliation. care to recognize the value and necessity of primary care,15. Te EP who transitions a patient to another setting ofwhere family medicine physicians are the cornerstonecare or provider of care or refers the patient to another and primary building block of any academic institution.provider of care should provide asummary care record Table 2 illustrates the many areas of overlap between MUfor each transition of careor referral. and PCMH.www.greenbranch.com| 800-933-3711| 334 Medical Practice ManagementMarch/April 2014Table 2. Meaningful Use and Patient-Centered Medical Home Alignment Feature MU-PCMH Alignment Privacy Protect EHRs/secure electronic messaging Using patient data Record and chart vital signs Record smoking status Imaging results/information accessible through EHR Lab test results in EHR as structured data Generate lists of patients by conditions Surveillance data to public health agencies Patient education/self-care Clinical summaries to patients for each visit Patients can view online, download, and transmit health information within 4 business days Identify patients for preventive/follow-up reminders EHRs identify/provide patient-specifc educationCare coordination Summary record for each transition or referral Medication reconciliation from other provider/setting Prescription management Electronic prescriptions and CPOE Decision support Use clinical decision support to improve performance on high-priority health conditions Disparities Record demographics as structured data Reporting Report clinical quality measures to CMSElectronic data to immunization registries CMS, Centers for Medicare & Medicaid Services; CPOE, computerized provider order entry; EHR, electronic health record; MU, Meaningful Use;PCMH, Patient-Centered Medical Home.Source: National Committee for Quality Assurance; www.ncqa.org/Portals/0/Public%20Policy/MU%20PCMH%201pager.pdf. PCMH and MU require changes in provider and quality and continuity of patient care, and access to healthclinic behavior. Primary care physicians must be able information by increasing patient engagement in healthto adapt and evolve as the medical climate changesmaintenance through the efective use of HIT, interdisci - around us. Primary care physicians must incorporate all Y plinary teamwork, and a PCMH partnership. aspects of the clinic from the front desk, to nursing staf,to lab/x-ray technicians, to nonphysician providers inREFERENCES this transformation. Primary care must learn to develop 1. Leatherman S, McCarthy D. Quality of Health Care in the UnitedStates: A Chartbook, 2002. Te Commonwealth Fund; 2002. “team concepts” to manage its population of patients. 2. Joint Principles of the Patient Centered Medical Home. www.pcpcc. Population-based health is the responsibility of all peoplenet/content/joint-principles-patient-centered-medical-home. Ac- in the healthcare feld. cessed August 12, 2012. As medical care is in a state of constant reform, physi -3. Centers for Medicare and Medicaid Services. Medicare ElectronicHealth Record (EHR) Incentive Programs; www.cms.gov/EHRIncentivecians must stay informed in order to receive maximumPrograms. Accessed August 20, 2012. reimbursement while still providing high-quality care to 4. Centers for Medicare and Medicaid Services. Electronic Healthpatients. As has been the trend, insurers are following CMSRecord Incentive Program FAQs; https://www.cms.gov/Regulations- standards in the new wave of quality reporting. and-Guidance/Legislation/EHRIncentivePrograms/downloads/ FAQsRemediatedandRevised.pdf. Accessed September 25, 2013. Change is coming! Primary care providers must lead the 5. Murphy K. Meaningful Use: Stage 1, Stage 2 Comparison.way and educate nonphysician providers, nurses, and an- EHRintelligencecom. September 20, 2012; http://ehrintelligence. cillary staf for the new era of medicine and federal regula - com/2012/09/20/meaningful-use-stage-1-stage-2-comparison. Ac - tions. Te goal for primary care physicians is to improve the cessed September 25, 2013. FREE CODING ENCYCLOPEDIAand QUESTIONS ANSWEREDwww.greenbranch.com| 800-933-3711Reproduced with permission of the copyright owner. Further reproduction prohibited without permission."