There are many rules being promulgated to insure that EMR’s are safe vehicles. The first set of rules to have a major impact on health information systems in recent years was the Health Insurance Portability Act (HIPAA). As it relates to EMR’s, HIPAA requires providers to transmit their billing information in a specific format. The format, ANSI, was a complete and utter change from the existing format which took many years to develop. The rules originally stated for all providers, payers, and clearinghouses were mandated in 2002 to convert to the new standard and all electronic transactions were to be governed by this rule. I will spare you the details. First, only the providers and CMS are forced to this. Commercial payers and clearinghouses have various loopholes and exclusions. It is so bad that I now have more interfaces to various payers for our clients then ever before and providers are still bound to do whatever the payers want if they expect to get paid. I will give you an example of how bad this is. CMS was bound by Congress not to accept paper claims after a certain date. There are times when the primary insurance for an elderly person is not Medicare but another commercial payer. Once the commercial payer pays their portion, Medicare becomes what they call the secondary payer and they are to pay the remainder. However, the secondary payer, in this case Medicare, cannot accept paper claims. However, the primary payer will not send back the proper information electronically to the provider or does not send any electronic information--they only take paper. The provider had no way of creating an electronic secondary payment in their information system because they did not get the electronic information back correctly from the commercial payer (the commercial payer was exempt from doing this). Medicare commissioned someone to create a software program that allowed payers to manually put in the information so it would create an electronic secondary claim to be sent from Medicare.
To make matters worse in some cases Providers had their claims denied (they did not receive payment until they could submit these claims electronically) As a result, the provider had to purchase a system to create electronic claims but still had to manually create these claims because they could not get electronic claims information back properly from the commercial payers. My company had to recreate this software inside our program so that we could make it more efficient for customers to create these claims. This is one of many issues. HIPAA regulations also require providers to have security policy and procedures in place to insure that only the appropriate personnel have access to medical records and confidentiality requirements to make sure information is released only to the people the patient wants. However, releasing the information for treatment purposes or to insurance companies as it relates to a specific charge for services is exempt.
Most recently providers have been asked to start using e prescribing. They are being awarded 2% more in their Medicare fees if they use an e prescribing package. Most of these packages cost physicians more money and certainly more time to use than simply writing a prescription on a prescription pad. Under e prescribing, before they give you medication they are suppose to check how much the medication costs (they have to pay for a feed to a database that updates this information in real time), they have to check to see if the patient is eligible for a medication benefit (they have to pay for a feed to connect to payer plans to see if the patient has a prescription benefit), they have to be able to check to see if the medication they are prescribing is paid for by the patient’s plan (formulary check) (again they have to pay for a feed to a database that will keep this information up to date in real time), and they have to be able to send the prescription in a standard format that has been approved by the government to the pharmacies (they pay for a clearinghouse to send these transactions to all the different pharmacies that are in the area); otherwise, they would have to develop interfaces to all of them. Here’s the catch. Insurance companies are getting a fee from the government to administer the part D program and Pharmacies are getting fees from the insurance companies to distribute the medications, but until recently they have been exempt from having to do e prescribing.
Recently, the government has seen this as such a problem (physicians have tried to comply but they are having many problems because the infrastructure for the pharmacies is not ready) that they are mandating that by April of 2009 that insurance companies who manage a Part D Program have to comply with the same standards which they are forcing on physicians; however, the kicker is that it is still a voluntary program for Pharmacies. However, if the doctor does not use e prescribing and just prints the prescription on paper and gives to the patient they don’t have to abide by these rules until 2013 when they begin losing money for not doing it (disincentive program). Oh, by the way, when was the last time you were charged when you called the doctor’s office to ask for a refill? Never! They don’t receive any additional money to prescribe your medication. Don’t be surprised the next time you call your physician for a refill that they say you must come in to the office and see the physician or nurse first. That way the physician can at least charge you an office visit so that they can pay for e prescribing module. How is this going to reduce the cost of medicine?
I have explained the federal requirements, but it doesn’t stop there. States can make up their own rules regarding e prescribing and I know of one state where they think the federal requirements are not restrictive or strong enough and they have created their own certification process. Each vendor has to certify in that State if they want to offer e prescribing to their customers. Their standards make it even less efficient for the provider and more costly as compared to the Federal standards. To make matters worse, The Federal Trade Commission has now issued new rules and regulations called “Red Flags” that apply to any organization (that allows customers or patients to pay over time), including your doctor’s office, to put in an anti identity theft program. One way around this is to make the patient pay all their fees at the time of service.
In summary, any new electronic record mandates need to be thought through at the physician practice level. In the past these new initiatives have gone through expert committees and vendor groups for comments. Unfortunately, these expert groups have good lobbyists and they are stakeholders with something to lose or gain. Hardly any of them have practice medicine and some of them have implemented a EMR in a physician practice. The one group that we never get much comment from, usually because they don’t have the time to even look at the regulations let alone take the time out of their practice to meet on the topics is the physicians or their staff. I could fill several pages with details on these and other regulations that are being required and expected of physicians who have EMR’s. Again, I don’t see these as encouraging EMR adoption but rather discouraging adoption.
You might think that I am anti-standards and anti-regulations. It might even surprise you that I was among the first 7 vendors who joined to form the certification committee. What happened? The results so far has produced more restrictions, higher cost, and greater barriers to entry. In short EMR adoption has not increased. The two things that will increase adoption of EMR’s are simply lower the cost of entry and create products that make the physician workflow more efficient. For physician efficiency means doing more with the same or less resources (they make more money) or they make the same amount of money in less time (they go home early)
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