5 Things Surgery Centers Need to Know About Meaningful Use and the 50% Rule

The following article is written by Sean Benson, cofounder and vice president of consulting with ProVation Medical, part of Wolters Kluwer Health.


The march towards meaningful use (MU) has created a sense of urgency within the physician community to adopt EHRs for their offices — as it should. Hospitals and eligible professionals (EPs), which include physicians, began attestation for MU incentive payments on April 18, and the first payments were issued in May.


Central to physicians qualifying for stimulus payments is the use of certified EHR technology. Vendors began applying for certification in July of 2010, and physicians have begun the process of either choosing appropriate technology or making needed changes to existing systems in order to qualify.


With $27 billion in incentives up for grabs over the next five years and the potential for penalties hanging in the balance for providers who do not meet criteria, the stakes are high. But like any rush to a deadline, it's important that providers and ambulatory surgery centers understand the full picture and take a careful, thoughtful approach to choosing systems that align with both workflow needs and future expectations to avoid the potential for costly mistakes.


ASCs are becoming increasingly aware of the MU provisions — specifically as they relate to the perceived need to deploy a certified EHR as opposed to a system that may be more appropriately aligned to their environment. Since ASCs are not eligible for stimulus payments, and MU certification criteria for ASCs were never developed, there has been no real incentive or benefit for them to invest in certified systems. However, some ASCs are now feeling pressure to purchase a certified EHR and make costly technology decisions in order to satisfy the needs of their physician base.


This pressure is the result of a little-known clause in the meaningful use regulations, referred to as the 50 percent rule. A clear understanding of the 50 percent rule and four other aspects of MU is imperative for ASCs and EPs as they weigh their responses to the mounting external pressures to deploy certified EHR technology.


1. 50 percent rule. According to CMS, "any eligible professional demonstrating meaningful use must have at least 50 percent of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives."


The latest guidance from CMS is that, when they refer to a "practice/location," ASCs are included in that definition. Additionally, CMS has commented that "equipped" means that the technology needs to be available in such a way that the EP can use a certified EHR to accomplish all of their MU objectives.


This clause can potentially have the unintended consequence of leading ASCs to believe that they need to adopt certified technology that is not designed for their environment, and for which they receive no stimulus payments, unlike EPs and hospitals.


2. Potential solutions. ASCs under pressure to adopt a certified EHR product should first have their physicians determine where their encounters occur. If at least half occur at an office or offices equipped with certified EHR technology, then there is no need for that physician to be concerned about the 50 percent rule.


In cases where a physician does have more than 50 percent of patient encounters occurring at an ASC, there are two options that exist for the center: 1) significantly change the workflow within the ASC and the physician's office to capture data associated with MU objectives, or 2) encourage physicians to carefully review the CMS definition of an encounter and potentially change the way in which they schedule their patient activity to avoid falling short of the 50 percent rule.


According to CMS, for the purpose of calculating this 50 percent threshold, any encounter where medical treatment and/or evaluation and management services are provided should be considered a "patient encounter."


3. Workflow challenges. MU criteria were designed to address longitudinal patient care and a move towards the efficient electronic capture of patient data over time. To meet this need, EHR vendors have designed products to capture patient information over the course of many encounters.


It is a workflow that fits well in a physician office environment. But an ASC is much different. To efficiently address the workflow needs of an ASC, products need to be designed around procedures. That is, data capture needs to address the specific needs of a particular procedure being performed. This will not typically require the extensive evaluation that may occur in a physician office.


There are numerous examples of MU objectives that do not fit well within an ASC's workflow. For example, a meaningful user must use a certified system for the following types of workflows, many of which do not translate well into the ASC environment:

  • Computerized provider order entry
  • Drug/drug interaction checking
  • Drug formulary checking
  • Prescribing electronically
  • Reconciling medications
  • Incorporating clinical lab results into the EHR
  • Calculating and reporting clinical quality measures to CMS
  • Providing clinical summaries to patients
  • Submitting data to immunization registries and public health agencies
  • Keeping problem lists, medication lists and medication allergy lists updated


To be a meaningful user, either the ASC or the physician's office will have to significantly change their workflows to meet these types of requirements.


4. What's in it for ASCs and EPs? Simply put, the answer to this question is "very little," at least for ASCs. For physicians, working with an ASC that utilizes certified technology can eliminate concerns over running afoul of the 50 percent rule. This, in turn, can potentially benefit the ASC through higher satisfaction rates. However, that is where the benefits to the ASC end.


Indeed, ASCs that choose to significantly change their workflows and use certified EHR technology, as it is currently defined, will face costly uphill challenges related to administrative needs and productivity, with no stimulus dollars to back the effort and no guarantees of ROI.


It is also important to reiterate that it's not enough to make the investment in a certified EHR. In order for physicians to meet MU criteria, they have to demonstrate appropriate use of that product.

There is no getting around the workflow challenges. Not only will ASCs have to make the initial infrastructure investment, they, or the physician's office, will also have to address the workflow challenges in order for their physician base to qualify for MU stimulus funds.


5. What else can be done? ASCs need a voice in this issue going forward. There is much at stake if the expectation becomes that ASCs invest in a certified EHR, and there is little to gain without the ability to qualify for incentive payments.


ASCs should become more actively involved in the MU dialog via associations and direct communication with CMS. They should request that the 50 percent rule be clarified and that ASC certification criteria be developed and stimulus funding be made available if ASCs are going to be required to be a part of the MU discussion.


Physicians and physician associations should become more vocal on this topic as well, particularly for specialties in which a large percentage of encounters occur outside of an office-based environment. Having ASCs modify their workflows in order to demonstrate MU, as it is currently defined, will lead to both duplication of effort and decreased productivity.


Sean Benson (sean.benson@provationmedical.com) is cofounder and vice president of consulting with ProVation Medical, part of Wolters Kluwer Health.

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