An Overview of MU Strategy in making choices relevant to the CQMs (not MU Measures) in the incentive program

The strategy for CQMs is simple: try to comply with the needs for the 3 Core CQMs. After that, all the decisions are made for you. VeinDraw was designed with a CQM strategy that selected the three Additional CQMs based on (a) their overlap with the 3 Core CQMs and (b) the ease with which they can be ignored for the most part by phlebologists. The specifics of the CQM strategy include the following tips and suggestions:

1. Try to get at least one patient into the denominator of each of the 3 Core CQMs because if you end up with a zero in any of the 3 Core CQMs, you will have to replace that CQM with an Alternative CQM. In my opinion, the Alternative CQMs are more difficult to achieve.

a. Hypertension Assessment: To report on this CQM it means that for at least one patient who has (a) two encounters during the RP and (b) the diagnosis of hypertension (not necessarily the finding of hypertension), you have to record the BP of that patient at least once. To do this you simply have to alert your staff to be on the lookout for patients who carry the diagnosis of hypertension, and measure their blood pressure. In those patients for whom you record their blood pressure, you should consider NOT recording their height and weight.

b. Tobacco Use & Intervention screening pair. This CQM has TWO parts: Part 1 is Use and part 2 is Intervention. To report this CQM you need to have a non-zero denominator for both.

i. Tobacco use: Find patients aged 18 years or more with whom you have had two encounters during the reporting period and have been queried about tobacco use on at least one occasion, and the results of that query were recorded in the EMR as structured data.

ii. Tobacco Intervention: For those patients in (i) above who are active users of tobacco, you should “intervene” by discussing with them that they should quit, and record that in the EMR as structured data.

Clinical Quality Measures (CQMs)

This is an area that has generated concern for all EPs and phlebologists in particular. The requirements are clear that the Clinical Quality Measure’s objectives cannot be excluded and must be reported, even if the denominators are zero. However, the VTS staff is firmly convinced that it is an important strategy to make sure that there are no zeros in the denominators of any of the Core CQMs because the Alternate CQMs are much more difficult to achieve. But what if the required core, alternate core, or other measures do not encompass the type of patients that an EP typically sees? Is it OK to report a zero? Is it OK to report zero for all measures if no measures apply? The answer is yes and is clearly defined in the CMS guidance.

From CMS: EPs are not excluded from reporting clinical quality measures, but zero is an acceptable value for the CQM denominator. If there were no patients who met the denominator population for a CQM, then the EP would report a zero for the denominator and a zero for the numerator. For the core measures, if the EP reports a zero for the core measure denominator, then the EP must report results for up to three alternate core measures (potentially reporting on all 6 core/alternate core measures). For themenu-set measures, we expect the EP to report on measures which do not have a denominator of zero. If none of the measures in the menu set applies to the EP, then the EP must report on three of such measures, report a denominator of zero, and then attest that the remainder of the menu-set measures have a value of zero in the denominator.

Exclusions and Rationale for Some of my Recommendations

Core and Menu Objective Exclusions

There are 15 Core Set Objectives; Eligible Providers (EPs) must meet all 15 in order to qualify for incentive payments. There are 10 Menu Set Objectives, and EPs will “defer” (i.e., exclude) 5 of these Objectives and must meet the remaining five in order to qualify for incentive payments. At least one of the Menu Set Objectives must either be 1M or 2M. The EP can elect to satisfy BOTH 1M and 2M. This is VeinDraw’s recommendation because they both come with the software and are easy to satisfy. There are exclusions available for some, but not all, of the Core and Menu Objectives because they are outside the scope of most phlebology practices. Six of the 15 Core Objectives have exclusions but only four of them apply to phlebologists. Eight of the 10 Menu Objectives have exclusions but only five of them apply to phelbology.

Suffice it to say, there are enough exclusions and provisions in the Meaningful Use requirements and regulations that will allow phlebologists to meet Meaningful Use guidelines without having to significantly change the way they practice. If an EP cannot meet a specific Meaningful Use objective because it is outside of the scope of their practice, they may be allowed to exclude that objective. Even better, an objective that is excluded can count the same as if that objective was met. In the Menu Set, where the EP must choose 5 of the 10 objectives, if 2 of the objectives don’t apply, that EP would then only have to meet three of the remaining Menu Set Objectives.

Allowable, desirous and easy exclusions for Core Objectives

Objective 1C: Use Computerized Provider Order Entry (CPOE)

Exclusion: Any EP who writes fewer than one hundred prescriptions during the EMR reporting period.

Objective 4C: Generate and transmit permissible prescriptions electronically (eRx)

Exclusion: Any EP who writes fewer than one hundred prescriptions during the EMR reporting period.

Objective 8C: Record and chart vital signs

Exclusion: Any EP who believes that all three vital signs (combined together) to include height, weight and blood pressure have no relevance to their scope of practice. If the phlebologist feels this way he or she may attest so and thereby exclude this objective.

Allowable, desirous and easy exclusions for Menu Objectives

Objective1M: Capability to submit electronic syndromic surveillance data to public health agencies

Exclusion: Any EP that does not collect any reportable syndromic information on their patients during the EMR reporting period.

Objective2M: Capability to submit electronic data to immunization registries

Exclusion: Any EP that has not given any immunizations during the EMR reporting period.

Objective 3M: Drug-Formulary Checks

Exclusion: Any EP who writes fewer than one hundred prescriptionsduring the EMR reporting period. Note: It is important to claim this exclusion if it was claimed for 1C and 4C.

Objective 4M: Lab results

Exclusion: Any EP who orders no lab tests whose resultsare either in a positive/negative or negative numeric formatduring the EMR reporting period. Since this objectivewill probably be deferred, the exclusion is moot.

Objective 6M: Send reminders to patients based onpatient preferences and selected by specific criteria

Exclusion: Any EP who has no patients 65 years old or olderor 5 years old or younger. Since this objective is hard to excludeand since the list just has to be produced (and printedand filed away) it should be attested to with a “Yes”.

Objective 7M: Provide patients with timelyelectronic access to their health information(including lab results, problem list, medicationlists, and medication allergies) within 4 businessdays of the information being available to the EP

Exclusion: An EP that neither orders nor creates lab tests or information that would be contained in the problem list,medication list, medication allergy list (or other information as listed at 45 CFR 170.304(g) during the EHR reporting period. Since this objective is hard to exclude and since the software makes it happen automatically, you should just put the numerator and denominator from your Vein- Draw MU report into the CMS attestation website.

Objective 8M: Patient Educational Resources

Exclusion: NONE: Since this objective will probably be deferred, the exclusion is moot. If for some reason you have strong feelings that you want to INCLUDE this requirement in your attestation, please talk to your VTS support staff.

Objective 9M: Perform medication reconciliation

Exclusion: An EP who was not the recipient of any transitions of care during the EMR reporting period. Since this objective will probably be deferred, the exclusion is moot.If for some reason you have strong feelings that you want to INCLUDE this requirement in your attestation, please talk to your VTS support staff.

Objective 10M: Provide summary carerecord for each transition of care

Exclusion: Any EP that does not transfer a patient to another setting or refer a patient to another provider during the EMR reporting period. Since this objective will probably be deferred, the exclusion is moot. If for some reason you have strong feelings that you want to INCLUDE this requirement in your attestation, please talk to your VTS support staff.

Patient Encounters vs. Unique Patients

The definition of what constitutes a "patient encounter" is critical to the ability of many phlebologists to develop a strategy to successfully meet Meaningful Use and receive the CMS EMR incentives. Much of the documentation and attestation of "meaningful use" is based on "patient encounters.”

CMS clearly distinguishes between the terms “Unique Patient” and “Patient Encounter.” They are not used interchangeably and must be considered when calculating patient volume thresholds and measures. CMS chose to use “Unique Patient” over “Patient Encounter” in measuring objectives related to patient’s medical records. It was assumed that not all of the “Unique Patient” information would need to be updated or needed by the EP at every patient encounter.

Unique Patient

• If a patient is seen by an EP more than once during the EMR reporting period, then for purposes of measurement, that patient is only counted once in the denominator for the measure.
• 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 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 EMR reporting period.

Patient Encounter

• Face-to-face meeting between patient and EP.
• Results in a billable claim.

Medicaid Encounters

• Services rendered on any one day to an individual for where Medicaid or a Medicaid demonstration project under section 1115 of the Act paid all or part of the service; or
• Services rendered on any one day to an individual for where Medicaid or a Medicaid demonstration project under section 1115 of the Act paid all or part of their premiums, co-payments, and/or cost-sharing.

Relevant Encounter

• EP performs a medication reconciliation due to new medication or long gaps in time between encounters.
• Other reasons determined appropriate and judged to be so by the EP.

Groups of Related MU Objectives:

The Three “Allow Patient Access to Medical Records” Groups

There are THREE Meaningful Use Objectives that focus on the requirement for providing patient’s with access to their medical records. This is a summary of those three objectives:

1. All three require that patient(s) “receive” (C12), or “are provided” (C13), or “have timely access” (M7) to their clinical summaries.
2. NONE OF THEM DEFINE WHAT IS MEANT BY RECEIVE, OR IS PROVIDED, OR HAS ACCESS, so it is hard to define when the objective is satisfied. NONE OF THEM REQUIRE PROOF OF “RECEIPT” OR “PROVISIONING” OR “ACCESS” OTHER THAN ATTESTATION.
3. In fact, M7 (Timely Access) goes so far as to state that “The objective and measure focus on the availability of access and the timeliness of data, not utilization. The EP is not responsible for ensuring that 10% request access or have the means to access, on that 10% of all unique patients seen by the EP could access the information if they so desired.” It also states “Online electronic access through... a patient portal... will satisfy the measure of this objective.”
4. All three require that the objective is completed within 3 or 4 business days; no problem for a patient portal.
5. Each of them has a different “trigger” to start the timing of the above time requirement.
1. a. C12 (On Request) = At time of REQUEST.
2. b. C13 (Each Visit) = At completion of an OFFICE VISIT.
3. c. M7 (Timely Access) = Whenever ICD9, Labs, Prob List or Med List changes. (For our practice this means anytime an encounter is completed.)
6. Two of the three (M7 (Timely Access) & C12 (On Request) require electronic information. The other (C13) is non-specific (could be paper or electronic.)
7. Because we are handling all three of these through the portal, the access will always be electronic, although for 2/3 it is not required.
8. All three talk about providing patients with access to their “health information”. But later all three clarify this by saying “clinical summaries” is the minimum required (Problems, Labs, Meds, Med Allergies.)
9. Each of them focus on different patient populations for the denominator:
1. a. C12 (On Demand) = # of patients who REQUEST a copy
2. b. C13 (Each Visit) = All Office Visits
3. c. M7 (Timely Access) = All Unique Patients.

NOTHING in the MU descriptions, authoritative Blogs, nor “Additional Information” has ever suggested that we are required promote the availability of this service; nor even to inform the patient that the service exists. I think this last bit could be going too far, so my advice to our clients on this issue is as follows: Include a short sentence at the bottom of your registration page or HIPPA information form like this: “An electronic summary of your basic medical information is available if requested.” Personally, I think this will pass muster with any review, given the minimal requirements and vagueness of these three objectives.

The Three “Medication” Objectives

Exclusions Pertaining to Prescriptions

There are THREE Meaningful Use Requirements: 1C, Use Computerized Provider Order
Entry (CPOE) for Medication Orders; 4C, Generate and Transmit Electronic Prescriptions (E-Rx); and 3NM, Implement Drug-Formulary Checks. All use the same exemption: “any EP who writes fewer than one hundred prescriptions during the EHR reporting period.” The following details regarding this exemption are important to note:
1. The first year you participate, your Reporting Period (RP) will be 90 calendar days, which is approximately 65 days if you are seeing patients 4 days per week, or 52 days if you are seeing pat ents 5 days per week. This means that you will qualify for the exclusion if you write an average of less than 1.9 prescriptions per day (for 4 days per week) or less than 1.5 prescriptions per day (for 5 days per week.) Since the vast majority of full time phlebologists only see patients 4 days per week, most phlebologists will probably qualify for this exemption. (I know I will be exempt.)
2. I heard rumors of physicians (not phlebologists) who are planning to claim this exemption by writing prescriptions on paper prescription pads and not recording this information in the EMR as structured data, reasoning that this work-around would go undetected since there are no “Attestation Police” and since the Certified Technology has no way of reporting paper events. Therefore, these physicians are willing to take the infinitesimal risk that they might be discovered. Although I have heard rumors of this plan, I do not recommend it.

Exclusions Pertaining to Vital Signs

Meaningful Use Requirement 8C (Record Vital Signs) requires that the EP uses certified technology to record three vital signs in the EMR: Height, Weight, and Blood Pressure. The exclusion is “any EP who believes that none of the three vital signs have relevance to their scope of practice.” The following details are important to note:

1. This rule is based on the number of Unique Patients, not Encounters. This rule does NOT require that the VS are ever updated, so if a patient has all 3 vital signs recorded during the Reporting Period (even if each of the three VS were recorded by themselves and just once on two or three separate encounters), then that patient counts in both the numerator and the denominator.
2. This is a “no partial credit rule” because an EP must attest that NONE of the three vital signs are relevant. If the EP believes that one or two of these vital signs are relevant to their scope of practice, then in order to get credit for meaningful use, they must record all three vital signs in order to meet the measure of this objective.
3. I also note that if an EP believes that all three vital signs of height, weight, and blood pressure are irrelevant to the scope of their practice (like I do), then there is nothing wrong with recording some of these vital signs some of the time for irrelevant reasons; like if the patient requested it or if the EP is collecting and recording this information for the sake of appearances, which is what I do. 4. Therefore, I will claim this as an exclusion, but will use the certified technology to record this structured data occasionally for irrelevant reasons.

Exclusions Pertaining to Meaningful Use Requirement 12C (Provide patients with Electronic Copy of their Health Information Upon Request)

Meaningful Use Measure 12C requires that EPs provide an ELECTRONIC copy of a Clinical Summary UPON REQEST within three business days of the request. Almost all EMRs that are fully certified have dealt with this issue by creating a patient portal. NOTE: It is not REQUIRED for the certified EMR to create a patient portal, but most have because the alternatives place undue burden on the EP for complying with this measure, so before you purchase your EMR, make sure you understand how this MU requirement will be dealt with. With a portal, clinical summaries can be accessed by the patient with very little effort on the part of the EP’s staff, and with zero effort on the part of the EP. The exclusion is “any EP who has no requests from patients for an electronic version of their clinical summary.” The following are important details regarding this requirement and its exclusion:

1. There is no requirement to promote this service to your patients. You do not have to advertise it, mention it, send a letter, or tell them it is available in any way.
2. Similarly, there is no requirement that you tell your staff that this service is available.
3. The minimum amount of information required in the “Clinical Summary” is just a list of medications, medication allergies, problem list and diagnostic test results. For many patients, receiving such a list will be a disappointment and will result in multiple phone calls to your office demanding that the “clinical summary” be embellished or corrected. 4. Given the fact that this would be a new service for most practices, it is very likely that if the service is not promoted, patients will never ask for it.

Exclusions Pertaining to Meaningful Use Requirement 4M (Incorporate clinical lab-test results into EMR as structured data)

Meaningful Use Measure 4M requires that 40% of all labtests ordered by the EP have their results entered into the EMR as structured data; provide an ELECTRONIC copy of a Clinical

Objective: Capability to submit electronic data to immunization registries. The exclusion is: “If any EP orders no lab-tests whose results are either in a positive/negative or numeric format, during the reporting period, they would be excluded from this requirement.” Important details regarding this exclusion:

1. Most phlebologists do not order tests. Those who do order occasional tests are ordering imaging tests (CTV, MRV, venograms, etc.), which (by CMS standards) are all classified as interpretive tests, not positive/negative numeric tests. The most common lab tests that are occasionally ordered by phlebologists are tests for thrombophilia.
2. The exclusion goes away if you order even one numeric or +/- test during the RP.
3. Similar to the rumors I have heard regarding ordering medications, the author has also heard rumors of physicians (not phlebologists) who are planning to claim this exemption by ordering laboratory tests on paper forms and not recording this information in the EMR, reasoning that this work-around would go undetected since there are no “Attestation Police” and since the Certified Technology has no way of reporting paper events. Therefore, these physicians are willing to take the low risk that they might be discovered. Although I have heard rumors of this strategy, I cannot recommend it.

Comments Regarding Meaningful Use Requirement 6M (Send Reminders to Patients)

Meaningful Use Measure 6M requires that 20% of all Unique Patients seen during the RP are sent an “appropriate reminder” for preventative/follow-up care. In my opinion, this is the MU requirement that received the least amount of thought, discussion, attention, or whatever was needed to create a clear requirement. Apparently, the authors of this Requirement assumed that for every subspecialty, there were multiple, clearly defined, “appropriate” guidelines for preventative care for a large number of patients who were commonly seen in a practice, and that the “appropriate” guidelines were backed by clear scientific evidence, and widely accepted by the medical community as good and useful guidelines.

The few noncontroversial guidelines that exist in the field of phlebology regarding preventative care for common conditions revolve around the use of compression hosiery for preventative care. These “compression hosiery guidelines” are so pedestrian and possibly controversial that they are (in my opinion) not very “appropriate” (e.g. all patients with venous disease should wear medical grade support hosiery.) The few other guidelines (those that are not centered on prophylactic compression) are aimed at using prophylactic medications, activities, and compression stockings to prevent thrombosis in clinical situations (thrombophilia, severe uncorrectable CVI due to isolated deep system incompetence, etc.) that are relatively infrequent. So infrequent, that during any 90 day period of time it is probable that in some practices that the number of patients who might present with those clinical features that would make preventative or follow-up care appropriate or useful would be ZERO. Yet Meaningful Use Requirement 6M does not allow for that possibility that during a 90 day reporting period! Unfortunately, not only has CMS failed to allow exceptions to this requirement (like there were no patients who presented during this RP who had the need for preventative reminders), but CMS has not defined what is meant by an “appropriate” reminder. Therefore, if an EP does not report something for this requirement during their RP, they will fail to achieve MU.

For this reason, phlebologists who want to achieve MU are encouraged to send at least 20% of their patients aged 5 to 65 a letter (assuming this is their preferred method of communication) stating that it is good medical advice to wear support stockings if flying for more than six hours straight. Silly, I know, but it is easy to do and it gets the job done. Comments Regarding How You Will Get Paid EHR Incentive payments are paid directly to the EP in a single consolidated annual payment. Payments will be made as soon as the EP has attested and reached the threshold for maximum payment. EPs can attest to meaningful use before they have reached the $24,000 threshold. All payments will be made to the EP unless the EP has a valid contractual arrangement which allows the entity or facility to bill for the providers services and the EP has reassigned the incentive payment to that entity. EPs cannot reassign their incentive payments to more than one employer or entity. The EPs enrollment information will disclose if the EP belongs to more than one practice by the association of their NPI. If the EP is associated with more than one entity the EP must select one TIN to receive the incentive payment.

Comments Regarding Multiple Locations

Objectives that use measures based on percentages require that at least 50% of an EPs patients are included in the measure. Denominators are derived from either those patients whose records are maintained using certified EHR technology or all patients seen or admitted during the EHR reporting period, regardless of whether their records are kept using certified EHR technology. For EPs that provide services in more than one location, they must determine what patients are correctly counted in the denominator. I cannot imagine how CMS could monitor the number of non-Medicare patients who were included or excluded in these totals.

According to the Program rules, EPs participating in the Medicare program and practice in multiple locations must have at least 50% of their encounters during the RP in location(s) equipped with an EMR. Every encounter in Places of Service (POS) except a hospital inpatient department (POS 21) or a hospital emergency room (POS 23) can be included in the denominator of the calculations. This would include all encounters in an ambulatory surgical center (POS 24).