Recently I reviewed the framework CMS is using for the EHR incentive program. You may recall that many of the meaningful use objectives have thresholds which must be met in order to successfully demonstrate meaningful use. The threshold is simply a fraction in which the denominator defines the patients or actions of interest and the numerator registers the action taken for the patients in the denominator.
The thresholds vary from 10% to 80%. This wide variation reflects CMS’s perception of both the importance of the objective and their recognition of existing practical limitations to attaining high thresholds in certain circumstances. Today I will review the three meaningful use objectives that present the highest hurdle to clear:
1. Problem List
2. Medication List
3. Medication Allergy List
Each of these three objectives shares the same denominator. The denominator for these objectives is the number of unique patients seen by the EP during the EHR reporting period. The phrase “unique patients” is further clarified in the final rule as follows: If a patient is seen by the physician more than once during the EHR reporting period then for purposes of measurement, they only count once in the denominator for the measurement. The final rule goes on to state, “All the measures relying on the term ‘unique patient’ relate to what is contained in the patient’s medical record. Not all of this information will need to be updated or even be needed by the provider at every patient encounter. This is especially true for patients whose encounter frequency is such that they would see the same provider multiple times in the same EHR reporting period. Measuring by every patient encounter places an undue burden on the EPs, eligible hospitals and CAHs and may have unintended consequences of affecting the provision of care to patients merely to comply with meaningful use.” This framework has important implications for the nephrologist (as I discuss below).
With the denominator clarified let’s turn our attention to the numerators for these three measures. They are actually very easy to understand. The Problem List measure is looking for at least one problem (or the designation that the patient has no problems) on the problem lists for all of the patients in the denominator. This problem list must be codified, which in the outpatient setting typically means every problem is identified by an ICD-9 code. Similarly the Medication List measure is looking for at least one medication (or the designation that the patient takes no medications) on the medication list for all patients in the denominator. Finally, the Medication Allergy List measure is looking for at least one allergy (or the designation that the patient has no known medication allergies) on the medication allergy list for all patients in the denominator. In addition to sharing a common denominator, there are no exclusions for these three meaningful use objectives. All three are also core objectives and are therefore required for every nephrologist participating in the program.
What’s the practical implication for the nephrologist attempting to demonstrate meaningful use? There are several. First, the timing of fulfilling the numerator is open; that is to say CMS is interested in making sure you have access to the problem list, medication list and allergy list at the time of your encounter. These lists can be created before the visit but must be viewable during the encounter. This means you should begin using these features of your EHR today if you intend to demonstrate meaningful use in the near future. Also note the physician is not compelled to create these lists. It is appropriate for your office staff to do so, as long as the lists are available for your review during the encounter within the EHR reporting period. Finally, depending on the relative volume of your office-based practice and dialysis practice, you may be required to report on your dialysis patients. If you find yourself in this situation, these three objectives will likely apply to your dialysis population. I plan to devote a future post to this very important nuance of the EHR incentive program.
Bottom line
The threshold for these three meaningful use objectives is set high at 80% of your unique patient encounters within the reporting period. Start now and make sure you have the appropriate process in place to insure problem lists, medication lists, and allergy lists are being created for your patients. This will save you time and effort next year during the EHR reporting period.
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