The CMS EHR Incentive program contains a hurdle of special interest to the nephrologist, which I will refer to as the “50% rule.” Effectively this rule states that in order to be eligible for the incentive a provider “must have 50 percent or more of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology.” What defines a patient encounter within the 50% rule? Hospital visits are excluded from the 50% rule as CMS expects those to be conducted within a hospital based EHR. Encounters within the dialysis unit, however, are included in this calculation; and herein lies the rub.
What actually constitutes an encounter in the dialysis unit is not specified in the final rule. The CMS EHR incentive as written is intended to apply broadly to all providers although in many instances it appears the audience is the primary care provider. In fact, the 50% rule is in play so that providers in multiple locations are not excluded if one or more of those locations do not have a certified EHR.
What impact will the 50% rule have on you and your practice? The answer in large part depends on how the encounters in the facility are counted. From my perspective there are three possibilities:
1. Count every face-to-face encounter (e.g., 4 visits per month).
2. Count the complete or comp visit as care is rendered in the dialysis facility within a capitated framework (e.g., 1 visit per month).
3. Count unique patient encounters—a phrase used throughout the rule to tabulate individual meaningful use measures (e.g., dialysis patients would be counted 1 time during the reporting period).
Why is this distinction important? Let’s consider a few hypothetical scenarios:
Suppose option 1 is ultimately considered the appropriate metric. If the nephrologist follows 100 dialysis patients and sees each patient 4 times per month, over the 90 day reporting period that’s 1,200 patient encounters. On the other hand, suppose option 3 is the correct way to count. In this case the nephrologist has 100 patient encounters in the dialysis unit over the 90 day reporting period. Now consider your office-based practice. Suppose you see patients 3 half days per week and during those half-day clinics you see an average of 10 patients. That’s 30 patients per week and 390 patients during the 90 day reporting period. (Let’s round up to 400 to make the math easy.)
Now back to the 50% rule. If I do not take my certified EHR into the dialysis unit and option 1 is the answer, I am not eligible for the EHR incentive; 400 ÷ (400 +1200) is less than 50%. If option 3 is the answer I am eligible for the incentive; 400 ÷ (400 + 100) is greater than 50%. In this circumstance (option 3, no EHR in the dialysis unit) I would report the meaningful use objectives only for my office-based patients.
Suppose I take my certified EHR into the dialysis facility. Now regardless of how the dialysis visits are counted I am eligible to participate in the EHR incentive. The difference in this case is I must now include the dialysis patients in the population of patients I report the meaningful use objectives. This is where the math gets a bit interesting. Remember that the meaningful use objectives can be divided into two groups: those with a threshold to meet and those that require a simple yes or no answer. It is the former group of objectives I need to pay close attention to when I take my EHR into the dialysis unit.
Let’s continue down this path by exploring the example of the high threshold meaningful use objectives—problem list, medication list and allergy list. The threshold for these three measures is 80%. Of interest to the nephrologist, the denominator for these measures is made up of “unique patient encounters.” Now look at our example above. Those 100 dialysis patients represent 100 unique patient encounters even if I saw them 12 times during the 90-day reporting period. What about those 400 office encounters? Perhaps 300 were unique patients and 100 encounters were follow up visits. If I capture a problem, med and allergy for every office patient and ignore the dialysis patients I will miss the mark for these three objectives (300 ÷ 400 = 75%).
What is the solution? One is to make sure every dialysis patient has an ICD-9 code on their problem list (the vast majority of your dialysis patients should have 585.6 on their problem list). What about meds and allergies? When you bring your certified EHR into the dialysis facility you are bringing your e-prescribing tool. Make sure to use it in the dialysis unit and your EHR will populate the patient’s med list and allergy list. Note the mathematical nuance that surrounds the definition of unique patient encounter. Unless I “live” in the dialysis unit and see no one in the office, I am unlikely to miss the other meaningful use objectives as the thresholds for those measures are much lower. Of additional interest, consider what will happen after the first year when the meaningful use reporting period expands from 90 days to the entire year. What takes place in the dialysis unit becomes mathematically less important when the reporting period expands.
In my travels around the country I have encountered a wide variety of dialysis rounding schedules and strategies. If you wish to participate in the CMS EHR incentive program you need to pay close attention to the intersection of your rounding schedule and the 50% rule. The simple scenario above is intended to stimulate conversation around this important aspect of the meaningful use final rule. I am very interested in your thoughts and comments, so please share them here.
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