With the Aprima PQRS feature fully validated, providers who use the Aprima EHR can begin sending data to the federal CMS data registries and realizing the financial rewards of providing excellent (and well-documented) care. CEO Michael Nissenbaum says, “This PQRS validation is just the latest evidence that the Aprima EHR is out in front of the competition. We’ve always felt that we provided a significant advantage to physicians who use our system, and it’s nice to get this third-party proof.”

In addition to the EHR, Aprima Medical Software products include a fully integrated Practice Management (PM) system as well as a Revenue Cycle Management (RCM) service to help practices maximize reimbursement and minimize payment time. The user-friendly Aprima EHR is chief–complaint-driven and offers adaptive learning capability based on each provider’s habits. The unique Intuitive Navigation approach quickly displays clinically relevant content based on the presenting chief complaint, speeding up the physician’s documentation. Aprima’s robust PM software includes all the tools a busy practice needs to manage its patient population, including insurance eligibility, optical character recognition for automating data input, and built-in robust/customizable reporting capabilities.

The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed rule.  HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius.  “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead.  We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10.  Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.

Another provision would extend the outpatient hold-harmless payments for qualifying rural hospitals and sole community hospitals with fewer than 100 beds through Dec. 31, 2012. The hold-harmless payment provides a payment that is equal to 85% of the difference between an eligible hospital’s outpatient prospective payment system and the hospital’s costs, according to a summary of the bill prepared by the staffs of the House Ways and Means and Energy and Commerce Committees.

The bill would also extend the outpatient therapy cap exceptions process through Dec. 31 and extend—also through the end of December—the following ambulance add-on payments: 2% for urban ground ambulance services, 3% for rural ground ambulance services, and an increase to the base rate for ambulance trips that start in so-called “super rural” areas.

As expected, lawmakers had to agree on ways to pay for the Medicare spending in the bill, which amounts to about $21 billion over 10 years. One so-called “offset” in the agreement would lower the reimbursement level that Medicare pays hospitals for bad debt payments. Currently, Medicare reimburses hospitals and skilled nursing facilities for 70% of the beneficiary cost-sharing they are unable to collect, while community health centers and dialysis centers are reimbursed at 100%. The bill agreed in conference would decrease the reimbursement level to 65% starting in fiscal 2013 for those providers currently reimbursed at 70% and phase in the 65% level over three years for those other providers who now receive 100% reimbursement. These changes are expected to reduce spending by about $6.9 billion over 10 years.

Another provision would reduce payment rates for clinical laboratory services by 2% in 2013. Then, as that reduction is applied after the update is calculated, the 2013 amount would become the new “reset base” on which to apply the 2014 update. According to the summary, the bipartisan Congressional Budget Office estimates this provision could cut spending by about $2.7 billion over 10 years. This provision is expected to take a serious toll on small, independent labs that deliver testing in the nation’s nursing homes, according to Julie Allen, government relations director at Drinker, Biddle & Reath in Washington. And these labs will already face a 1.75% cut in reimbursement for 2013, Allen explained.

“I think it’s a matter of not being considered on the merits of health policy and healthcare business, but a matter of trying to scrape together dollars in the midnight hour,” Allen said of the measure. “We talk so much about seniors’ access to their physician providers, but we’re talking about patients with high level of chronic disease managed by physicians who need to run lab tests.”

The American Hospital Association weighed in on the agreement, saying Congress has put seniors’ access to hospital services in jeopardy.

“Today’s proposal would add an unnecessary strain to hospitals that care for vulnerable populations,” Rich Umbdenstock, the AHA’s president and CEO, said in a statement. “It limits therapy services provided in hospitals and assistance that helps defray Medicare and Medicaid costs to low-income seniors,” he continued. “This is shortsighted and overlooks the critical role hospitals play in supporting a broad range of services to the elderly.”

The practice has used an electronic medical record system for eight years and recently implemented e-prescribing; a website with comprehensive patient information; and a portal where patients can update their medical history and contact information and request prescription refills.

Despite the cost and initial sacrifices associated with EMR and other technologies, “we’re not done yet,” said Kristen Kratzert, MD, a partner in the three-physician obstetrics and gynecology practice in Syracuse, N.Y. She said Women’s Wellness Place plans to implement a knowledge-based system to aid in patient management and diagnostics and online scheduling in the near future.

“We’re always trying to make our practice better and more efficient,” Dr. Kratzert said.

Practices such as Women’s Wellness Place are investing in the technologies that involve helping the patient make his or her own experience more efficient — and, as a result, helping the physician make the practice more efficient.

“It’s a really exciting time in health care,” said Deanna R. Willis, MD, a family physician in Indianapolis, associate professor at Indiana University and chief medical officer of quality and medical management for the 200-physician Indiana University Medical Group Primary Care. “I think if we look at the banking industry over the past 10 or 15 years, and the way they have automated with ATMs and online account management, we’re about to take a similar leap forward in health care.

“Eliminating unnecessary waste from the processes that support the [doctor visit] helps the patient feel like their time is valued,” Dr. Willis said, especially when patients believe the real value of a visit “is the person-to-person interaction with the doctor.”

New communication tools

Patient portals, for example, allow both patients and physicians to communicate over a secure website to share test results, schedule and cancel appointments, make online payments, and review or add prescription and other patient information.

“A portal can provide a [Health Insurance Portability and Accountability Act]-compliant and secure way to communicate with a patient,” Dr. Willis said. “If a patient reviews their medication list and health history before they go into the office, it will be more accurate, safer and more efficient for the office team.”

Through in-office patient kiosks and tablet computers, patients also can update health and insurance information and consent documentation before they see the doctor. With education materials — provided online or at an in-office work station — patients view information relevant to their condition and age and in their primary language.

In addition, some practices are using online coaches to help patients improve their diet or manage a chronic condition.

“A coach can touch more people in a Web environment than face to face,” Dr. Willis said. “Online coaching also can reduce emergency department visits and hospitalizations and effectively change outcomes. This will be particularly important for practices working to adopt patient-centered medical home formats.”

For many doctors, the challenge is if they have the time or money to implement these technologies. Fortunately, many are offered through a physician’s existing EMR software.

Thirty-four percent of all U.S. physicians and 39% of all primary care physicians had EMR technology in 2011, according to the Centers for Disease Control and Prevention. Yet most of these practices are not implementing the expanded communication tools that their systems provide, such as portal services for making appointments, said Rosemarie Nelson, a Syracuse, N.Y.-based principal with the Medical Group Management Assn. health care consulting group.

Electronic scheduling, prescription management and patient portals often are available, or can be added to an EMR system, for a nominal fee — $20 to $45 per month or on a per-transaction basis, Nelson said.

Other systems and upgrades may require a greater investment.

Tablet- and kiosk-based systems, for example, can cost between $2,000 and $5,000 up-front, Nelson said. These systems may require an additional $3,000 to $5,000 for installation, staff training and set-up; $2,000 to $10,000 to fully integrate them into the physicians’ systems and procedures; and, in some instances, a $250 to $400 monthly user fee.

For staff, technologies that manage a practice’s administrative functions can mean drastic changes in responsibilities and procedures.

“I do think [new systems] require you to think about the roles in your practice,” said Timathie Leslie, vice president of Booz Allen Hamilton, who specializes in health care information technology.

For example, “a portal can be a very efficient way to communicate with a physician, as long as there are processes in place within the practice for reviewing and responding to new information,” Dr. Willis said. However, “if the office is not responding in a timely manner to a request placed in the portal, the patient is going to have to pick up the phone and call the physician’s office. Now the office has to deal with both the phone call and the new portal information.”

Getting patient buy-in

Dr. Willis also said patient input, acceptance and knowledge of these new technologies are critical to success.

“Listening to the customer and understanding what the customer wants and needs is essential to designing any changes in office processes,” Dr. Willis said. The process can be “informal” — simply asking patients for their opinion on a proposed change — or involve the expertise of an external facilitator to manage focus groups and provide a more comprehensive assessment.

“Seeking input from patients doesn’t have to be difficult, yet it is essential,” Dr. Willis said.

Nelson suggests informing patients of new technologies and procedures at various stages of the office visit.

“Practices with the most success in getting patients to use new tools introduce [them] in the exam room,” Nelson said. “The nurse explains the what, why, etc.”

Then, at checkout, patients are told how to access their lab results, email the physician and use any other new communication tools. Someone in the reception area can be designated to assist patients with a new waiting room kiosk.

Ultimately, integrating these new technologies will save time and money, Nelson said.

“I’ve done a cost-value analysis,” Nelson said. “The transaction fee [for portal use] is less than … the staff time and benefits that you are utilizing to complete these tasks. If we trade that value, it’s clearly a deal.”

Meaningful use bonuses offered by the U.S. Centers for Medicaid and Medicare for practices that upgrade their patient technology offer further incentives.

Physician practices and hospitals are eligible for bonuses — up to $44,000 through Medicare and $63,750 through Medicaid — for meeting federal EMR objectives. For the moment, many technologies that would improve office efficiency aren’t included in the criteria for bonuses.

But beginning in 2014, physicians will need to include greater patient access through e-prescribing, Web-based portals and online patient messaging and payment to continue to receive bonuses. Insurance companies and employers also are offering incentives for improving practice technology, patient-physician communication and information access.

“We’re entering meaningful use phase 2 with a greater emphasis on the exchange of information and quality measurement,” Leslie said.

Although not every technology that focuses on efficiency is eligible for Medicare or Medicaid bonuses under meaningful use, practices are finding that systems that allow for a more streamlined process can cut costs and boost patient satisfaction.

Customer demand also will be a market force as more patients — and even new medical school graduates — choose practices that provide the latest technologies.

“We’re going to select our provider network based on the ease of access and the ability to track care online, especially as we start to manage chronic illness and the care of our parents and children,” Leslie said.

Using federal data, the National Conference of State Legislatures has compiled a report that shows Florida state agencies, universities, hospitals, public clinics — even faith-based private groups such as Tallahassee-based Live the Life Ministries — received funds from the Affordable Care Act in 2010 and 2011 for everything from clinic expansion to abstinence lectures.

This has happened while Florida has been a leading state in a lawsuit alleging that the Obama administration act is unconstitutional. What’s more, NCSL reports Florida is one of three states planning to ask voters next fall to consider a constitutional amendment to declare illegal key provisions of the reform act — a stance that could lead to a state-federal court battle if the amendment were to win approval.

Scott, former leader of the HCA hospital chain, has been highly vocal in opposing the reform act, passed by Congress in 2010 with its most important provisions scheduled to start in 2014.

Shortly after his election in 2010, Scott announced he didn’t want the state to accept $1 million in federal money — already accepted by his predecessor, Gov. Charlie Crist — that was intended to help Florida set up a health insurance exchange, a system in which small employers and individuals can join together to get lower rates usually available only to large employers.

Scott spokeswoman Jackie Schutz said the governor “believes it is imprudent to accept taxpayer money and the obligations associated with those funds if they are predicated upon implementation of a law whose constitutionality has not yet been determined by the Supreme Court.”

She said that the Scott administration “carefully evaluated all federal funding opportunities” and accepted some funds in the reform act, such as abstinence counseling, because they are not tied to implementing the act.

Scott’s administration also turned down an additional $1 million intended to help states determine if health insurers were seeking unnecessarily large rate increases.

Jack McDermott, spokesman for the Office of Insurance Regulation, said the consumer funds were rejected because of concerns that accepting the $1 million would allow the federal government too much control of state insurance activities.

In other cases, Florida didn’t qualify for healthcare funds not connected with the reform act, such as the $296 million in bonuses awarded by the feds in December to states that had done a good job in providing health insurance for children. Much smaller states raked in considerable amounts, such as Alabama, which qualified for $19.8 million.

Other states have been aggressive in pursuing funds to help the poor and uninsured get better healthcare. California has received more than $40 million to set up exchanges, according to NCSL. Altogether, California has pulled in $600 million in reform funds in the past two years.

Steven Ullmann, a health policy expert at the University of Miami, said the exchanges “are critical to the implementation of healthcare reform,” a way of maintaining the present system of private health insurance while obtaining affordable premiums for the poor and uninsured.

Ullmann said some states, including Florida, are engaged in an “interesting gamble” by not preparing for the major reforms in 2014 because they are guessing they will never be implemented. If that bet is wrong, Florida and others will have to play catch up — and may lose control of the exchanges to the federal government. The act has a clause that if states haven’t made sufficient steps toward setting up exchanges by January 2013, the federal government could take over the process.

Despite the Scott administration’s opposition, Florida still ranks 10th among states in what it’s received from the $4.1 billion in reform act funds distributed in 2010 and 2011, according to the NCSL.

Most of that has gone to non-state agencies, which Scott has no control over, such as $14.5 million to expanding community health centers that serve the poor and uninsured. Of those funds, the North Broward Hospital District received $2.9 million for its clinics, according to federal reports.

Because the act emphasized the need for more primary care, federal reports show the University of Miami and Nova Southeastern each received $416,000 for training specialists in geriatric care — primary care for the elderly. Miami’s Children’s Hospital received $4.8 million for expanding pediatric residency programs, another form of primary care.

Research initiatives, too, received funds. One major South Florida recipient: Bio-Nucleonics, a Doral biotech firm, got nearly $1 million to pursue development of four cancer drugs.

One state agency that did benefit was the Department of Health, which received $2 million in September 2010, before Scott took office, to expand services. After Scott became governor, the state received $5 million in September 2011 for home visiting programs to check on children in at-risk families, according to a U.S. Health and Human Services press release.

While the governor continues to oppose what conservatives call “Obamacare,” the Obama administration has called the reform act a success in Florida, pointing out that the act saved the state’s seniors $141.9 million last year because it decreased the size of the “doughnut hole” for Medicare drug costs. The administration also says the act helped 3,300 uninsured Floridians with serious medical conditions obtain insurance coverage through a high-risk pool called the Pre-Existing Condition Insurance Plan.

In one category, Florida has ranked near the top of reform funds: abstinence counseling to reduce teen pregnancy. Florida has received $2.6 million for the counseling, behind only Texas and New York, according to the NCSL.

The abstinence money was once cut from the bill because some Obama administration healthcare leaders believe such counseling isn’t effective, but it was later reinserted by Democrats in a failed attempt to get Republican support.

UM’s Ullmann says that such additions are often necessary, particularly in controversial healthcare legislation: “You have to make parties happy… Some people may not buy the central concept, but are attracted by something else.”

The state health department received the abstinence funds, according to a federal website. Other Florida groups received another $8.8 million in other teen pregnancy counseling, with $891,000 of that going to Live the Life Ministries, with a mission of “strengthening marriages and families.”

Richard Albertson, chief executive of the ministries, told The Herald the funds are the first of five equal annual grants for a teen counseling program called Wait, which emphasizes that “abstinence is the best choice.” Albertson said the program is part of a research effort, with a Florida State University professor comparing those who go through the ministries’ program with a control group. Albertson said the program is also being watched by the Mathematica Policy Research, a Princeton-based nonprofit that has previously published studies finding no difference between teens who go through abstinence programs and those who don’t.

Although he accepted the federal money for his program, Albertson said he wasn’t sure he supported the reform act. He said the act is “so massive and complicated that America is still learning what it’s about.”

A grand opening of the three-story CAMLS building, which at 90,000 square feet is billed as the largest facility of its kind in the world, is set for the end of March. Learners are expected to come from all over the world and will range from undergraduates to seasoned professionals.

But teaching already is under way, and officials have been giving a few tours, showing off the center’s main components:

• The ground floor houses the Surgical & Interventional Training Center, featuring three surgical skills labs, a trauma operating room, robotics training room and a first-of-its kind hybrid operating room. This room — a similar one is being built for actual patient care at Tampa General Hospital — offers unprecedented flexibility. If, for instance, a heart attack patient were brought in for a minimally invasive technique but was found to need open surgery, he could get it immediately without being moved.

• The Education Center makes up most of the second floor, and includes a 200-seat semicircular auditorium, three expandable 50-seat classrooms, a kitchen and dining space.

• The third floor contains a Virtual Patient Care Center, with more than a dozen smaller training and exam rooms and five larger team training rooms. It also has training pharmacies.

• The top floor also houses the Tampa Bay Research & Innovation Center, where medical faculty, engineers, computer scientists, management experts and industry partners can gather to work on projects, such as developing new medical devices.

“There is nothing else like it,” said Dr. John Armstrong, the facility’s medical director. He noted that most training and simulation centers in the country are far smaller than CAMLS, serve only one kind of professional rather than the entire team, and often use old equipment.

The new facility near the Tampa Convention Center allows for a world of possibilities, he said, chief among them the ability for all the members of a medical team — doctors, nurses, technicians — to train together. That team approach, and the ability to prove what works best for patients, is growing ever more crucial with today’s emphasis on evidence-based medicine, he said.

Some teams will train in settings that can simulate reality, to sometimes startling effect. Rooms will be equipped to simulate the sights and sounds of battle in Afghanistan so teams can prepare themselves for military medical service. Or the chaos of an urban trauma center can be digitally recreated.

So can warm tones and soft music to soothe patients whose procedures don’t call for general anesthesia. Simulated procedures can be recorded so teams can learn from their own performance.

All of the nearly 40 surgical stations are equipped for actual surgery, though the center isn’t licensed for patient care. But students will gain experience with real-world equipment.

Dr. Stephen Klasko, dean of the USF Morsani College of Medicine, said interest in the facility is intense. Representatives from groups such as the American College of Cardiology and two United Kingdom-based medical schools — St. George’s and Anglia Ruskin — are scheduled to visit in March. Klasko said the cardiologists’ group is considering making CAMLS its primary simulation training site.

CAMLS was awarded $750,000 last fall as part of a grant from the Department of Defense to investigate how best to train combat medics.

Klasko said USF has spoken with top health officials in Panama about building a similar training center there to serve Central and South America. “And these are not casual conversations,” he said.

The center has already received glowing reviews from U.S. Health and Human Services Secretary Kathleen Sebelius and Tampa Mayor Bob Buckhorn, both of whom attended a discussion there last week on women’s health issues.

Buckhorn expects CAMLS to generate a short-term economic boost from people training at the facility using downtown hotels and restaurants. Longer-term, the goal is to attract companies such as medical device manufacturers to set up in the area.

Buckhorn recently traveled to Israel to meet with executives from Simbionix, a manufacturer of medical training simulators, including some used at CAMLS.

“CAMLS is probably the most important development in downtown Tampa in at least 20 years,” Buckhorn said. “It’s a game-changer.”

The quality reporting program has been optional for physicians since its introduction in 2007, and technically it will remain voluntary. But starting in 2013, physicians who don’t report enough quality measures will not only forgo a bonus but also see an across-the-board cut in Medicare pay for 2015.

If the history of Medicare’s physician quality reporting system is any indication, many physicians could be exposed to the penalty, which starts at 1.5% for 2015 and increases to 2% for 2016 and beyond. Participation in the quality program has been lackluster, according to the latest Centers for Medicare & Medicaid Services report. Only about one in five physicians and other eligible professionals sent quality data to Medicare in 2009, and of those, only slightly more than half did a satisfactory enough job to earn a bonus.

A separate Medicare value-based purchasing program has the potential to decrease some physicians’ pay even more starting in 2015, also based on 2013 reporting. The PQRS is a pay-for-reporting program, but in an effort to move Medicare toward actual pay-for-performance, Congress authorized CMS also to use PQRS quality data and cost information from claims to make additional payment adjustments to selected physicians. That payment modifier will reduce pay for some doctors to reward other physicians who are deemed to provide higher-quality care at a lower cost relative to their peers.

The situation has stoked organized medicine opposition to CMS handling of the programs, which join similarly structured initiatives promoting electronic medical records and electronic prescribing. Physician organizations complain that doctors are subject to multiple, confusing requirements, and they say CMS is jumping the gun by holding reporting periods years before pay adjustments are made.

The American Medical Association is one of the groups opposing the CMS proposal for the pay-for-performance modifier and is fighting for the removal of all PQRS penalties, said AMA President Peter W. Carmel, MD. The Association objects to linking the 2015 penalties to 2013 performance, but it also has concerns about how CMS is administering all of the quality initiatives.

“Under current CMS rules, physicians must meet separate requirements for the e-prescribing, PQRS, [EMR] incentive and value-based modifier programs,” Dr. Carmel said. “These programs overlap, leaving physicians with unwarranted penalties for deciding to participate in one program over the other.”

CMS had considered using quality reporting in 2014 and 2015 to determine pay-cut recipients, but the agency concluded that basing the 2015 penalty on reporting during any year later than 2013 was not operationally feasible.

Physicians also will be flying blind next year when it comes to the value-based purchasing modifier. The modifier methodology will not be finalized until November 2013. That means physicians for the first year will have no way of knowing which doctors will be selected, and on what quality and cost standards they will be judged.

But doctors have had enough time to prepare for the value-based purchasing program even though the final details have yet to be determined, CMS says in its latest Medicare fee schedule. “We strongly encourage physicians to participate in the physician quality reporting system and the [EMR] incentive program sooner rather than later and to choose to report quality-of-care measures that best reflect their practice and patient population.”

Illinois State Medical Society President Wayne V. Polek, MD, said any effort to penalize doctors more is inappropriate when they already face Medicare pay cuts nearing 30% under the sustainable growth rate formula. Uncertainty about Medicare payments has weighed heavily on physicians considering investing time and money into complying with new Medicare quality initiatives, he said.

“The government is talking out of both sides of its mouth,” Dr. Polek said. “They can’t fix the SGR for a dozen years, and they wonder why doctors don’t want to participate.”

Unaware and uneasy

The Medicare physician quality reporting system requires doctors to report certain activities or data during specific patient encounters. For instance, one diabetes measure requires a doctor to report an eligible patient’s most recent hemoglobin A1c level as greater than 9%, between 7% and 9%, or less than 7%. The physician also can indicate that a patient’s level has not been measured for 12 months.

After the figures are recorded, physicians can use special codes on claims to report them. Other options for sending data include using third-party registry systems or EMRs that have the measures integrated.

Once CMS has the information, it’s up to program officials to determine if it’s enough. Physicians must report three or more individual measures during at least 80% of eligible patient encounters. Doctors who fail to report enough often will find out long after the fact that they missed the threshold.

Part of the problem is that, even at the start of the final penalty-free year for PQRS reporting, many physician practices still don’t know about it. “I don’t think awareness is very high,” said Bruce Bagley, MD, the medical director for quality improvement for the American Academy of Family Physicians.

For practices that do know about it, full compliance for bonuses has been elusive. The incentive for completing the program in the 2012 reporting year would be equal to 0.5% of a physician’s total Medicare charges for the year, paid as a lump-sum bonus. Doctors who take part in a maintenance-of-certification program can bump that incentive up to 1%. Federal law requires CMS to stop offering bonuses after the 2014 reporting year, at which point only penalties will be in play.

Leslie Spry, MD, and his partners at Lincoln (Neb.) Nephrology & Hypertension have reported quality measures since January 2008. However, they did not receive notice of their success for that first reporting year until the fall of 2009.

“You have no idea if you were doing it right or not,” Dr. Spry said. “A few of my partners didn’t quite do it right, so we didn’t get all the money we could have.”

CMS expects to start providing interim feedback reports to eligible professionals this summer so they can get an earlier sense of how they are doing. Those reports would be based on claims for dates of service between Jan. 1 and March 31.

Although the program requires physicians to submit data on only three measures to qualify, Dr. Spry chose to cover his bases by reporting nine of 10 individual quality measures. His office staff designed forms with checkboxes for measures related to diabetes, heart disease and kidney disease care.

“I try to do as many as possible and hope at least three of them would turn out OK,” said Dr. Spry, who ended up reporting all nine of the measures successfully.

Ingrained resistance

Others have not been so successful, and physician confidence in Medicare quality incentive programs is weak right now, said Joel Shalowitz, MD, clinical professor of health industry management at Northwestern University and president of The Medical Care Group in Chicago.

A few years ago, Dr. Shalowitz talked to his primary care group about PQRS. Doctors asked about the extra work involved and the potential reward at the end. They each could receive a relatively small bonus, he said, but they would not be paid until 18 months later. The group decided to hold off.

“It was a big disaster,” he said. “We’re glad we didn’t participate.”

Success rates among participants have struggled to get much higher than 50%. Final data on participation during the 2010 program year will not be available until late February, said CMS spokesman Joseph Kuchler. “However, I can tell you from a draft I saw that the numbers of successful participants and the incentives issued continue to rise.”

Dr. Shalowitz ascribed the low participation and success rates to the complexity of the PQRS. His medical group is installing an EMR, which would help compile quality data for transmission to CMS. But until then, the practice has decided that the process is too labor-intensive for physicians and office staff to accomplish.

Dr. Polek’s anesthesia group has reported quality measures since 2008. He said he has been successful reporting measures tied to quality efforts he has done all along, such as timing antibiotics for certain surgeries. But he worries about CMS moving to rely on data points that physicians can’t control. A physician charged with tackling obesity rates, for instance, can advise patients to exercise and diet, but it is the patients’ responsibility to act.

Last chance for warm-ups

Physicians who start participating in the PQRS now would have more latitude to experiment by selecting quality measures and determining how best to send them to CMS, Dr. Shalowitz said. Doctors can participate in 2012 without being penalized for a reporting mistake.

It will get harder. “There will be firm requirements for reporting conditions, and more and more will be required to avoid being penalized,” he said.

Doctors who have not started quality reporting should consider finding a registry-based reporting option for submitting data, Dr. Bagley said. Claims-based reporting can be too cumbersome for some practices, but a reporting registry can be more efficient and give faster feedback.

“If this is the way we have to go anyway, this is an easy way to get your toe in the water,” Dr. Bagley said.

He recommended that practices use a registry to report one of 22 measure groups, each containing four to 10 quality measures. CMS publishes a list of approved registries on its website. Most cost a couple of hundred dollars per doctor.

Measure groups cover such areas as diabetes mellitus, preventive care, heart failure and hypertension. Reporting a measure group requires the physician to send quality data for 30 patients, taking the guesswork out of whether the doctor met an 80% threshold.

“It puts you on the road to consistent quality improvement internally,” Dr. Bagley said. “No matter who measures you, you’ll be better.”

 ADDITIONAL INFORMATION:

Medicare’s bonus scorecard

Bonuses for successfully reporting quality measures and electronic prescribing started in 2007 and 2009, respectively. Bonuses for meeting electronic medical records requirements began in 2011 and will continue until 2016. These figures list incentives for the reporting year when a bonus can be earned, not when the physician would receive the bonus. A value-based purchasing modifier also would affect selected physicians in 2015 and beyond.

Sources: 2012 Medicare physician fee schedule; Medicare and Medicaid EHR Incentive Program Basics, Centers for Medicare & Medicaid Services

Over the past decade, the way that doctors approach this common clinical dilemma has been transformed with a simple innovation. A blood test for B-type Natriuretic Peptide (BNP), which is secreted by weakened heart muscle, can help distinguish between the two conditions. Another improvement in recent years: Doctors are replacing their stethoscopes with inexpensive, hand-held ultrasound scanners that can detect a failing heart right in the ER.

Such innovations are just the beginning of a transformation of medicine, says Eric Topol in “The Creative Destruction of Medicine.” Dr. Topol, a prominent cardiologist and geneticist, envisions a technology-enhanced future where new tools are integrated into diagnosing and treating patients, transforming the handling of common medical problems.

“The U.S. government has been preoccupied with health care ‘reform,’ but this refers to improving access and insurance coverage and has little or nothing to do with innovation,” even though, as Dr. Topol notes, adopting new approaches would improve care and lower costs. Doctors still “render medicine by the yard,” he says, and they follow insurance-mandated treatment guidelines that “are indexed to population rather than an individual.”

Dr. Topol is known for not being shy about expressing his views on medical matters—he was a prominent critic of U.S. drug-safety oversight during the Vioxx episode, when the arthritis and pain-relief drug was pulled off the market in 2004 after tests showed that it raised the risk of heart attacks and strokes. But in recent years Dr. Topol has taken a lower profile and has focused his work on how new technology is making the delivery of care more effective, giving doctors the tools to target treatments in ways that can maximize benefits and minimize harms. As the chief academic officer at Scripps Health, Dr. Topol has studied how academic healthcare organizations like Scripps can collaborate with for-profit companies to accelerate technological progress in medicine. This book communicates what he has learned.

“The Creative Destruction of Medicine”—an allusion to economist Joseph Schumpeter’s description of “creative destruction” as an engine of business innovation—is a venture capitalist’s delight, describing dozens of medical technologies that show great promise. The book also provides colorful anecdotes about Dr. Topol’s own sampling of these products, as both a doctor and stand-in patient

He continuously checks his blood sugar with an implantable meter, and he goes to bed wearing a “Zeo clock” that monitors brain function to help analyze sleep patterns. When he tries to fake sleep so that he can disregard his wife’s bedtime chatter, he learns that “it’s hard to play possum with a sensor displaying your real-time brain waves.”

Dr. Topol focuses much of his attention on the development of “theranostics,” or the integrated use of treatments and diagnostics (especially genomic and protein information) to better guide therapy. These tools, he says, will enable treatment systems that combine the constant monitoring of a patient’s biological information and the infusing of targeted medicines. The concept isn’t new, but Dr. Topol does an admirable job of laying out the ways in which it will help transform medical practice.

Diabetic patients, for example, will be grouped and treated according to genes that reveal “those who have problems with making or secreting insulin and those who have problems with the action of insulin in the body’s tissues.” The technology for doing this is available, yet in today’s medical environment—where patients are grouped into broad, crudely defined categories—these two kinds of patients aren’t well distinguished, even though they have very different clinical needs.

The book can be dense with data, but it offers enough explanatory detail to make such information accessible to experts and lay readers alike. Its most important contributions are in portraying how medical innovation will coalesce to change clinical practice and what the coming changes mean for today’s policy debates.

For instance, full adoption of the new tools will require the Food and Drug Administration to alter the way it evaluates products. The FDA, he says, should allow the testing of drugs on patients who are selected for their prospect of deriving a benefit. Right now, the FDA usually requires drugs to be tested in a scattershot fashion on large populations. With drugs being tested on cancer patients, he notes, the “FDA insists on a body count to be able to quantify how much and how long the new drug improves survival”—even though diagnostic markers can sometimes reveal in advance which patients are unlikely to gain a benefit.

Dr. Topol worries that doctors will resist technologies that empower patients because the tools will also diminish the doctors’ gatekeeper role. The American Medical Association, for example, battled firms that provide genetic information directly to patients. “This arrangement ultimately appears untenable,” the author writes, “and eventually there will need to be full democratization of DNA for medicine to be transformed.”

In Dr. Topol’s vision, innovation that enables real-time diagnosis and personalized treatments is a certainty, though not because reluctant or “sclerotic” doctors accept it or because Washington wills it into being. A seductive technology that works like a dream and improves lives will set off a consumer clamor, whether the new tool is an iPhone 4S or an implantable blood-sugar meter.

Black Book Rankings compiled its data by surveying EHR/EMR users about client experience and satisfaction key performance indicators; 13,000 viewpoints were collected. The survey was open via invitation and validated response audits from July 31 through October 15, 2011. Results were used to compile competitive rankings in forty categories, such as specialty, location, practice size, and ambulatory vs. inpatient practices.

“The Black Book Rankings validate what we hear from our customers: Aprima EHR offers everything they were looking for in a clinical system, and our partners and support team provide the support they need to make the most of it,” says CEO Michael Nissenbaum. “It’s even better to hear that they ranked us number one in the 6 to 25- doctor category against some very well -established players. We also ranked well in other size categories from 1 to 99 providers.”

Aprima Medical Software products include a fully integrated Electronic Health Records (EHR) and Practice Management (PM) system as well as a Revenue Cycle Management (RCM) service to help practices maximize reimbursement and minimize payment time. The user-friendly Aprima EHR is chief–complaint-driven and offers adaptive learning capability based o n each provider’s habits. The comprehensive intuitive knowledge base quickly displays appropriate content based on the presenting chief complaint, speeding up the physician’s documentation. Aprima’s robust PM software includes all the tools a busy practice requires to manage its patient population, including insurance eligibility, optical character recognition for automating data input, and built -in reporting capabilities, using Microsoft Reporting Services. The Aprima 2011 EHR is ONC Certified , enabling providers to be eligible for federal ARRA funding for Meaningful Use of an EHR.