Day in the life of Dr. Joe

The Economic Recovery Act and The Affordable Health Care Act have mandated that all health care providers adopt electronic medical records (EMR). As proposed and mandated the EMR is a dangerous sham.

Nearly thirty years ago I began to design my ideal medical office computer system. When I began my solo family practice in 1983 I immediately designed and implemented some of the system. Over time I was able to understand the information management needs of my practice and by 1996 I was able to fully implement my ideal "paperless office".

In that year I integrated then shredded the thousands of paper charts, some dating back over fifty years to my predecessor doctor. I now had nearly instant access to my patients' entire medical record. In the subsequent fourteen years I have continued to develop the system. I have designed it for maximum efficiency and ease of use. It allows me with a small office staff (equivalent to only two full time employees) to take care of the primary care needs of over three thousand patents. They are very pleased with my care. I see patients more often than not within hours of their call. I take or return all calls daily, and the time in the waiting room is reliably less than ten minutes. I see about thirty patients daily, occasionally as many as fifty. The electronic medical record facilitates this efficiency.

The components of the system are fully integrated. They include:
1- Patient demographics
2- Appointment scheduling
3- Billing
4- Problem list
5- Office notes
6- Lab reports
7- EKGs
8- Medication lists
9- Immunization logs
10- Word processors
11- Filed external documents (scanned paper)

Every exam room has an identical terminal. The front desk has two and the work room and lab and my office each have terminals as well. For just one doc and a few office workers there are eleven computers: you are never more than a few steps away.

The speed of the system is such that any piece of information is no more than a dozen key clicks and a split second of processing away.

The database is fully relational and related elements are a key click away. The data is fully indexed and searchable. (Computer talk for it is easy to find out anything you want to know, even if you have not decided yet what that is).

The lab drawn by 5 PM and sent to two different clinical labs is filed in the patients' record by 8 AM in the morning the next day, ready and flagged for review. The office notes are dictated (full text detailed SOAP notes) then transcribed and automatically filed in the patients' record. Prescriptions are easily typed in the record and refills are a single key click. The prescriptions are legible: they are printed in full text, ready for my signature. The record is updated automatically. The patient's problem list is automatically updated from their check-out diagnoses. Their immunization log is automated and tracks the lot number of the vaccines administered. EKGs are never paper (unless they must be given to someone else): they are recorded directly into the patient's record. A wide variety of reports and notes and referrals are automatically printed. Scanned documents, filed by patient ID, date, and type (well over a quarter million pages so far) are retrieved with a maximum of a dozen key strokes, the first page on the screen within two seconds and subsequent pages in a fraction of a blink. There are lots of interesting bells and whistles (such as memo flags that appear when an appointment is scheduled or a patient is checking out). Check out and patient billing are simplified by fully searchable CPT and ICD9 codes, and simple two-letter "quick codes" for common procedures and diagnoses. No demographic information requires re-entry.

The system is designed for complete on-site security. There is no connection to the Internet. Links to laboratories are done through secure dedicated lines or via intra-office data transfer. The data is protected by on-site and off-site backup servers. Off-site access is secure: I carry a back-up of the entire system compressed in my pocket: any computer with a USB port becomes a terminal with all the data readily available!

All together it is a "way cool" system and it not only documents everything well, but frees me and my staff for the real game: taking care of people.

And yet, this system fulfills NONE of the governmental mandates for an EMR. The "meaningful use" minimal requirements are:
1- electronic prescribing
2 - sharing of records
3 - documentation of quality

Other criteria include demographic uniformity and standardized formatting.

Fully implemented, electronic prescribing may reduce prescription errors. It is, however, designed to limit the formulary, save insurers money, constrain and normalize prescribing patterns, and MONITOR WHAT DRUGS YOU GET. (Is that in caps?)

Electronic record sharing essentially means that any government agency has access to everything that was confidential. Since the Internet is the medium used to share the records, you can be assured of privacy and security -- NOT. (Oops - caps again?)

"Documentation of quality" is code for "practice according to governmental standards", with direct penalties and censure for doctors out of compliance.



There is nothing in the requirements for any real benefit to patients or physicians. As mandated it is a true threat, strike that, a true guarantee of loss of privacy.


And the cost of implementation? The Economic Recovery Act hinted at a rebate of over $40,000 per physician to implement the system. In reality, the amount is far less and is available only to those doctors who participate in Medicare. All pediatricians and over half of all other physicians will be excluded from any financial support. Full implementation will cost a lot more. And there is a financial penalty for not implementing an EMR with the above mentioned "meaningful use" criteria.

Wake up physicians: you are being forced to do things that are counter to your science, beliefs, and practices! Wake up people: your rights are about to be terminated. Wake up legislators: you are meddling in things of which you have no knowledge which will result in damages far beyond your imagination.

On January 1, 2011, the SGR formula once again kicks in unless fixed, reducing payments to physicians by now 30% !!!!

The Affordable Health Care Act (often called "Obamacare"), thinks that primary care needs to be incentivised (a neologism of the first order), so starting in January, we primary care docs will receive an incentive payment, up to 10% of our Medicare fees. I have appended the article explaining this incentive below. Read it if you are a masochist. My head spun when I read it.

Not that they are sending mixed messages, but the net reduction in my Medicare income will be at least 20% come January. Most physicians will not be able to afford this.

The legislators are idiots. Pure and simple.

Let's see if the new senators and congressmen prove to be otherwise. I won't hold my breath.




Incentive Payment Program for Primary Care Services, Section 5501(a) of The Affordable Care Act
Provider Types Affected
Physicians and non-physician practitioners submitting claims to Medicare carriers and Part A/B Medicare Administrative Contractors (A/B MAC) for primary care services provided to Medicare beneficiaries are affected.
What You Need to Know
This article, based on Change Request (CR) 7060, explains that Section 5501(a) of The Affordable Care Act provides for an incentive payment for primary care services furnished on or after January 1, 2011 and before January 1, 2016 by a primary care practitioner. The incentive payment will be paid on a monthly or quarterly basis in an amount equal to 10 percent of the payment amount for such services under Part B. See the Background and Additional Information Section of this article for further details regarding these changes.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 1 of 6 MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 2 of 6
Background
Section 5501(a) of The Affordable Care Act revises section 1833 of The Social Security Act by adding new paragraph (x), "Incentive Payments for Primary Care Services." Section 1833(x) of the Social Security Act states that, in the case of primary care services furnished on or after January 1, 2011 and before January 1, 2016 by a primary care practitioner, there also will be paid on a monthly or quarterly basis an amount equal to 10 percent of the payment amount for such services under Part B.
Specifically, the incentive payments will be made on a quarterly basis and will equal 10 percent of the amount paid for primary care services under the Medicare Physician Fee Schedule for those services furnished during the bonus payment year. (For bonus payments to Critical Access Hospitals paid under the optional method, see Chapter 4, Section 250.12 of the Medicare Claims Processing Manual at http://www.cms.gov/manuals/downloads/clm104c04.pdf on the Centers for Medicare & Medicaid Services (CMS) website.)
NOTE: The new Health Professional Shortage Area (HPSA) Surgical Incentive Payment Program (HSIP) and the new Primary Care Incentive Payment Program (PCIP) will be implemented in conjunction with one another for CY 2011. A separate article will be available at http://www.cms.gov/MLNMattersArticles/downloads/MM7063.pdf upon release of CR 7063 CR for HSIP. The former "special HPSA remittance" will now be known as the "special incentive remittance". This change is necessary as the PCIP is open to all eligible primary care providers regardless of the geographic location in which the primary care services are being furnished.
Primary Care Practitioner Defined
Section 5501(a)(2)(A) of The Affordable Care Act defines a primary care practitioner as:
•
A physician who has a primary specialty designation of family medicine, internal medicine, geriatric medicine, or pediatric medicine; or
•
A nurse practitioner, clinical nurse specialist, or physician assistant for whom primary care services accounted for at least 60 percent of the allowed charges under the Physician Fee Schedule (PFS) for the practitioner in a prior period as determined appropriate by the Secretary of Health and Human services.
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 3 of 6
Primary Care Services Defined
Section 5501(a)(2)(B) of The Affordable Care Act defines primary care services as those services identified by the following Current Procedure Terminology (CPT) codes as of January 1, 2009 (and as subsequently modified by the Secretary of Health and Human Services, as applicable):
•
99201 through 99215 for new and established patient office or other outpatient Evaluation and Management (E/M) visits;
•
99304 through 99340 for initial, subsequent, discharge, and other nursing facility E/M services; new and established patient domiciliary, rest home (e.g., boarding home), or custodial care E/M services; and domiciliary, rest home (e.g., assisted living facility), or home care plan oversight services; and
•
99341 through 99350 for new and established patient home E/M visits.
　
These codes are displayed in the following table. All of these codes remain active in Calendar Year (CY) 2011 and there are no other codes used to describe these services.
Primary Care Services Eligible for Primary Care Incentive Payments in CY 2011
CPT Codes
Description
99201
Level 1 new patient office or other outpatient visit
99202
Level 2 new patient office or other outpatient visit
99203
Level 3 new patient office or other outpatient visit
99204
Level 4 new patient office or other outpatient visit
99205
Level 5 new patient office or other outpatient visit
99211
Level 1 established patient office or other outpatient visit
99212
Level 2 established patient office or other outpatient visit
99213
Level 3 established patient office or other outpatient visit
99214
Level 4 established patient office or other outpatient visit
99215
Level 5 established patient office or other outpatient visit
99304
Level 1 initial nursing facility care
99305
Level 2 initial nursing facility care
99306
Level 3 initial nursing facility care
99307
Level 1 subsequent nursing facility care
99308
Level 2 subsequent nursing facility care
99309
Level 3 subsequent nursing facility care
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 4 of 6 CPT Codes Description
99310
Level 4 subsequent nursing facility care
99315
Nursing facility discharge day management; 30 minutes
99316
Nursing facility discharge day management; more than 30 minutes
99318
Other nursing facility services; evaluation and management of a patient involving an annual nursing facility assessment
99324
Level 1 new patient domiciliary, rest home, or custodial care visit
99325
Level 2 new patient domiciliary, rest home, or custodial care visit
99326
Level 3 new patient domiciliary, rest home, or custodial care visit
99327
Level 4 new patient domiciliary, rest home, or custodial care visit
99328
Level 5 new patient domiciliary, rest home, or custodial care visit
99334
Level 1 established patient domiciliary, rest home, or custodial care visit
99335
Level 2 established patient domiciliary, rest home, or custodial care visit
99336
Level 3 established patient domiciliary, rest home, or custodial care visit
99337
Level 4 established patient domiciliary, rest home, or custodial care visit
99339
Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes
99340
Individual physician supervision of a patient in home, domiciliary or rest home recurring complex and multidisciplinary care modalities; 30 minutes or more
99341
Level 1 new patient home visit
99342
Level 2 new patient home visit
99343
Level 3 new patient home visit
99344
Level 4 new patient home visit
99345
Level 5 new patient home visit
99347
Level 1 established patient home visit
99348
Level 2 established patient home visit
99349
Level 3 established patient home visit
99350
Level 4 established patient home visit
　
Primary Care Incentive Payment Program (PCIP)
For primary care services furnished on or after January 1, 2011 and before January 1, 2016, a 10 percent incentive payment will be provided to primary care practitioners, identified as: (1) in the case of physicians, enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37-pediatrics, or 38-geriatrics; or (2) in the case of non-physician practitioners, enrolled in Medicare with a primary care specialty designation of 50-Nurse
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association. Page 5 of 6
Practitioner, 89-certified Clinical Nurse Specialist, or 97-Physician Assistant; and (3) for whom the primary care services displayed in the above table accounted for at least 60 percent of the allowed charges under the PFS for such practitioner during the time period that has been specified by the Secretary.
CMS will provide Medicare contractors with a list of the National Provider Identifiers (NPIs) of the primary care practitioners eligible to receive the incentive payments.
Eligible practitioners would be identified on a claim based on the NPI of the rendering practitioner. If the claim is submitted by a practitioner or group practice, the rendering practitioner’s NPI must be included on the line-item for the primary care service (identified in the above table) in order for a determination to be made regarding whether or not the service is eligible for payment under the PCIP. In order to be eligible for the PCIP, Physician Assistants, Clinical Nurse Specialists, and Nurse Practitioners must be billing for their services under their own NPI and not furnishing services incident to physicians’ services. Regardless of the specialty area in which they may be practicing, these specific non-physician practitioners are eligible for the PCIP based on their profession and historical percentage of allowed charges as primary care services that equals or exceeds the 60 percent threshold.
Beginning in CY 2011, primary care practitioners will be identified based on their primary specialty of enrollment in Medicare and percentage of allowed charges for primary care services that equals or exceeds the 60 percent threshold from Medicare claims data 2 years prior to the bonus payment year. A provision to accommodate newly enrolled Medicare providers will be released in 2011.
Coordination with Other Payments
Section 5501(a)(3) of The Affordable Care Act provides payment under the PCIP as an additional payment amount for specified primary care services without regard to any additional payment for the service under section 1833(m) of The Social Security Act. Therefore, an eligible primary care physician furnishing a primary care service in a HPSA may receive both a HPSA physician bonus payment under the established program and a PCIP payment under the new program beginning in CY 2011.
MLN Matters® Number: MM7060 Related Change Request Number: 7060 Page 6 of 6
Additional Information
If you have questions about this article, please contact your Medicare carrier and/or MAC at their toll-free number which may be found at http://www.cms.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS website. The official instruction, CR 7060, issued to your Medicare carrier and/or MAC regarding this change may be viewed at http://www.cms.gov/Transmittals/downloads/R2039CP.pdf on the CMS website.
News Flash - Each Office Visit is an Opportunity. Medicare patients give many reasons for not getting their annual flu vaccination, but the fact is that there are 36,000 flu-related deaths in the United States each year, on average. More than 90% of these deaths occur in people 65 years of age and older. Please talk with your Medicare patients about the importance of getting their annual flu vaccination. This Medicare-covered preventive service will protect them for the entire flu season. And remember, vaccination is important for health care workers too, who may spread the flu to high risk patients. Don’t forget to immunize yourself and your staff. Protect your patients. Protect your family. Protect yourself. Get Your Flu Vaccine - Not the Flu. Remember – Influenza vaccine plus its administration are covered Part B benefits. Note that influenza vaccine is NOT a Part D covered drug. For information about Medicare’s coverage of the influenza vaccine and its administration, as well as related educational resources for health care professionals and their staff, please visit http://www.cms.gov/MLNProducts/Downloads/Flu_Products.pdf and http://www.cms.gov/AdultImmunizations on the CMS website.
Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2009 American Medical Association.