The Federal government is making a big investment in time and money to get physicians onboard with computerized medical records. It’s not just that computerization will make your practice smarter and more efficient. The government sees computerization as a way to make sure the healthcare community is getting the information it needs to make quality medical decisions and achieve low cost, high quality results:
These are laudable goals, but there’s a catch. It takes extra time, effort and money for both the physician and their practices to make computerization really work. For medical information to be shared and available everywhere, complete and accurate information needs to be entered into the system – and in the correct manner. The physician is naturally central to this process and so all eyes are on the physician to make sure this happens.
Meaningful Use Stage 2 has some new requirements for the physician and some new techniques for monitoring physician adoption of electronic health records. You need to understand these changes so that you and your practice can adapt successfully.
1) Your new 2014 certified system will report Meaningful Use measures for you. Instead of your practice attesting manually as was done during Stage 1, most of the information submitted to the government for attestation will be generated automatically by your computer system. The system will record whenever you do and do not comply with Meaningful Use objectives and will report the measures for you.
2) You are required to share computerized patient charts with other clinical entities whenever a patient transitions away from your care to theirs. As you move responsibility for a patient to another care entity, you will be sending along a computer file, called the ‘CDA’, which will be comprised of the information you painstakingly entered into your computer system. This information includes problem lists, medications, medication allergies, orders, results, etc. You will want that information to be complete and accurate, and the onus will be on you to make sure that happens.
3) You are required to share the chart with the patient. After each visit, your practice will give the patient a summary of the visit, which will be generated from information entered into the computer system. Also, your practice is going to make your full internal chart available to the patient online. Patients will be able to share their charts with other care entities themselves. You will want to make sure your computerized charts are accurate and complete.
4) You will be sending the government quality reporting covering nine Clinical Quality Measures (CQMs). These reports come from your computerized system and will only be accurate if the information in your system is complete and accurate.
5) Your system will be alerting you with five or more clinical decision supporting interventions. As you open up the patient’s chart, the system will evaluate the patient’s medical record and provide alerts as needed for 5 different intervention rules. To avoid false alarms for yourself and your staff, the patient’s medical record will need to be complete and accurate. And you cannot turn these alerts off. Your computer system will share with the your automated attestation.
So all eyes will be on you, the physician for MU Stage 2. There are checks and balances in place to make sure the computerization is happening. To be sure, meeting Meaningful Use requirements in Stage 2 will be more difficult but with some education and focus you can ensure you are on track and successful.