Last fall in this blog I reviewed what, at that point, was understood about the intersection of the dialysis patient encounter and meaningful use. Since that time CMS has clarified their position both within the FAQ section of their website and through direct communication with several blog readers. I am indebted to David, Laura and Toni for sharing email responses they received from CMS that further clarify how we should account for these visits, which occupy a substantial part of the nephrologist’s work week. As I travel around the country, it is clear to me this particular nuance of the meaningful use framework has not been well publicized within the nephrology community. So, let’s take another look. The confusion begins with what I have come to call the “50% Rule” and ends with what CMS refers to as “Unique Patient Encounters.”
The 50% Rule
In an effort to not to exclude providers practicing in multiple locations, some with a certified EHR and others without one, ONC created an eligibility requirement that asks if half of your patient encounters during the reporting period took place in a location or locations equipped with a certified EHR. Imagine a primary care provider who spends 70% of her time in a main office location with a certified EHR and 30% of her time at a satellite office where documentation occurs in a paper chart. Applying the “50% Rule,” this provider would be eligible to demonstrate meaningful use and would report the meaningful use objectives for the patients seen in the main office (the one with a certified EHR). She would not report the meaningful use objectives for the patients she saw in the satellite office.
The big question: Who should be included in the denominator when calculating the 50% Rule? The answer: Every patient you encounter with the exception of those seen in the hospital (place of service code 21 or 23), including patients seen in a dialysis facility and/or an access center.
In my post last fall, one thing that was not clear was how to count the dialysis encounters. Suppose I see my dialysis patient four times during one month in the dialysis facility, performing three “basic” visits and one “complete” visit. Is that four encounters or is it one? Based on an email response from CMS, it is four visits with respect to the 50% Rule.
There is another bit of intrigue surrounding the 50% Rule and the practice of nephrology. It relates to the increasingly common scenario in which a Nurse Practitioner or Physician’s Assistant makes several of the monthly dialysis visits. This practice pattern reduces the impact the dialysis encounters will have on the provider’s calculation of the 50% Rule as the mid-level provider is now performing many of the dialysis encounters.
So where does this leave the practicing nephrologist who sees a lot of folks in the dialysis facility? Assuming I have a certified EHR in my office, if more than half of my patient encounters during the reporting period occur outside the office, I am faced with two choices:
1. Bring my certified EHR into the dialysis facility (or access center), or
2. Do not participate in the meaningful use program.
Unique Patient Encounters
Suppose I have a certified EHR, but more than half of my patient encounters during a 90-day reporting period occur outside my office. As suggested above, I can elect to take my EHR into the dialysis facility. If I do so, a “nephrology friendly” nuance of the meaningful use framework emerges.
As you begin to demonstrate meaningful use you will discover there are two fundamental types of Stage 1 meaningful use objectives: those with a target threshold and those without a threshold. The objectives of greatest concern in the dialysis facility are those with a target threshold. With rare exception the denominators for these objectives examine “unique patient encounters” as opposed to the kind of patient encounters we are compelled to consider in the 50% Rule discussed above.
What is a unique patient encounter from the perspective of ONC? Perhaps it is best explained using the problem list meaningful use objective. That objective states that at least 80% of my unique patient encounters during the reporting period must have either a problem on their problem list or a notation the patient has no problems (a rare occurrence in the practice of nephrology). If I see a dialysis patient four times each month during my 90-day year 1 meaningful use reporting period, those 12 patient encounters count as one unique patient encounter. That is to say, this patient appears in the problem list denominator one time. To make it into the numerator, during at least one of those 12 encounters, that patient must have had a problem on his problem list. What ONC recognizes within the context of the unique patient encounter is that I do not need to update the problem list every time I see the patient, but there should be a problem list present at some point during the reporting period in order for me to be deemed a meaningful user of my certified EHR.
In my experience, the contents of today’s blog represent the most confusing aspect of the meaningful use framework from the nephrologist’s perspective. And while I do not believe ONC set out to stick it to the nephrologist, it is pretty clear the program’s architects did not have us in mind when they created this component of the meaningful use framework. The confusion here often begins with the 50% Rule. Once you separate that requirement from the Unique Patient Encounter, you are on your way to becoming a meaningful user.
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