This will be a morning session covering sections 3

1. THIS SCHEDULE MAY BE MODIFIED DEPENDING UPON SPEAKER AVAILABILITY Dr Bogardus Susan Vannoni Dr Bogardus Scott Simmons Dr Bogardus Jeff Carlin This will be a morning session covering sections 3 Susan Vannoni Scott Simmons Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

2. Section 3 Radiation Oncology Electronic Health Records and Meaningful Use 11:15 to 12:00 010514 76 Modified for 02-21-14 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

3. What do we need to know about Electronic health records and meaningful use In Radiation Oncology Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

4. There has been A Very Fast evolutionary process in Radiation Oncology from paper charts to full electronic health records. I will attempt to explain the rules and requirements of the need for an EHR and meaningful use. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

5. 1 Our Machines went from this TO THIS 4 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

6. BUT WHAT REALLY MADE ALL THIS POSSIBLE? COMPUTERS! 2 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

7. 2 This actually is a control panel for an early model nuclear sub, mockup at the Smithsonian, it is a totally fake early computer picture. Scientists from the Rand Corp. have created this model to illustrate how a Home Computer could look in the year 2004. This advanced technology may not be economically feasible for the average home. This computer will require not yet invented technology to actually work, but we are confident that scientific progress required to solve this problem will occur. With teletype and Fortran language this will be easy to use. (Popular Science 1956) Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

8. Evolution of Health Records Our recording of patient care records is evolving along a very fast 5 year government mandated time line from HUNDREDS OF YEARS of paper charts to today’s computer driven paperless electronic medical records. We have an opportunity to truly improve on the old paper format, but we must be alert to what we change, how we change it, and what we truly “improve”. 2 12-80 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

9. Paper records 2 This format is unacceptable in today's world of technology Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

10. 2 NIB Electronically Generated Notes are Preferable and Required for Meaningful use of EHR. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

11. 3 When using cascading electronic records, data may be transferred, discarded, or added to as each new document is created INITIAL EVALUATION UNDER BEAM PROGRESS NOTES CLINICAL END OF TREATMENT SUMMARY An Electronic Medical Record makes all this very easy, the hard part is documenting when and where changes have occurred FOLLOW UP NOTES Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

12. Formatting is crucial Standardization of format is crucial for data interchange both within your own records and with outside electronic charts Poor formatting can lead to confusing questions and answers Consistency of format from one document to the next is very important Questions and answers should cascade from one document to the next, but the answers must remain current and correct Correct answers lead to a compliant document 4 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

13. 4 Most EHR’s utilize a Point and Click Questions/Answers process. The major differences between various EHR programs is the number of question and answer choices. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

14. 4 Custom Narration then Follows The Answers Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

15. E Prescribe rules 7 • Failure to eRx by 2011 has resulted in a loss of 1% of your Medicare payment. • eRx is a requirement of meaningful use. • eRx is covered if you have an approved EHR. • More about eRx later. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

16. Data Interchange 9 LOCAL EHR DATA From your site of practice HL7 INTERFACE OTHER EHR To another practice site Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

17. DATA BY INTERNET It is legal and much more efficient of patient and office registration time. Internet access requires a secure line known as a “portal”. These are practical using encryption programs that are commercially available. This is necessary with the mandatory requirements for Meaningful Use, EHR. If the patient requests their records by email, and they are aware of the potential for breach of privacy, and acknowledge such, then you may email the records to them. 9 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

18. 9 CLOUD PROCESSING There are many different clouds, cloud processing is not a single entity Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

19. CLOUD PROCESSING 9 • Data may be accessed from anywhere, anytime. • Reduction in hardware cost, all computing and storage is remotely located. • Cloud programs can run on the smallest most basic computers. • Software applications, licenses factored in. • No local server or computer needed. • Decreased local IT cost. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

20. 9 Server farm in a data center Access is controlled by armed guards, single point of entry, man traps, Iris scan, continuous video surveillance. Each server is completely encased, climate controlled, sealed to the floor, and locked. Because of security and redundancy, downtime is 0 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

21. NIB This is the cloud computer, a giant mainframe located in a remote secure location. The local user can be accessing an extremely complex program and database from a relatively simple laptop, desktop, tablet, or even a smart phone. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

22. Computer networking history The 1st recorded example was utilizing teletype to access a remote number calculating machine in 1940. In 1950 the military started linking multiple radar site computers. In 1960 American Airlines linked two IBM mainframes to develop the SABER computer-based reservation system. In 1965 the 1st WAN, wide area networking, became the basis for the Internet in 1969. 10 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

23. Computer networking history In 1969 the Air Force was linking computers together, email and file transfer became practical. In 1974 TCPIC, the language to carry information on the Internet was developed. LAN local area networks connect to WAN, wide area networks using Ethernet. Communication is by IP, Internet protocol language allowing all computers to communicate. Each computer has an IP address. A VPN, virtual private network, allows secure communication through the Internet. 2010 Cloud processing is nothing more mysterious than all of these processes combined into a very large computer storage area securely connected to many individual users. There really is no “Cloud” 10 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

24. Protected health information, PHI Part of the requirements for meaningful use is the ability to enable patients to have real-time access to their health records. You can actually hand them a hard copy, give it to them on a flash drive, or give them access to their records stored somewhere on a cloud processor such as health vault. ONCOCHART is the only radiation oncology EHR That offers cloud-based processing and data storage 10 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

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26. What are the EHR Incentive Programs? 11 EHR Incentive Programs were established by law as part of the American Recovery & Reinvestment Act of 2009. These are incentive programs for Medicare and Medicaid covering hospitals and eligible professionals Your program must use certified EHR technology AND demonstrate adoption, implementation, upgrading and Meaningful Use. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

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29. Original purpose of meaningful use Fewer redundancies in testing. Reduce medical errors. Improve communication between providers. Develop computer aided decision support. Better, prompt, patient access to medical records. Promotion of preventative healthcare. 11 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

30. 11 Meaningful Use Criteria THINK IRS Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

31. Eligible provider (EP) Dr. of Medicine, M.D. Dr. of Osteopathy, D.O. Dr. of Dental surgery or Dental medicine Doctor of Podiatry Dr. of Optometry Chiropractor NP, PA, (Medicaid incentive only) 11 Who is eligible to participate? Incentives are based on the individual, not the practice. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

32. Eligibility is Determined by Law Hospital-based EP's are not eligible for incentives 90% or more of their covered professional services cover inpatient care (POS 21) or emergency room care (POS 23) The definition of hospital-based is determined by law 11 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

33. PAYMENT FOR EHR USE The goal of CMS is to pay you, not prevent payment, the $ are there to be spent from the 2009 Stimulus bill. You must, however, have a fully certified and capable EHR and be using it. 80% or more of your active records must be electronic. 12 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

34. These amounts are “per physician”. The last year to start receiving incentives is 2014. Starting MU in 2015 will result in NO incentive payments. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

35. Medicaid Incentive Program 13 NOTICE NO REDUCTIONS Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

36. Physician Loss for failure to update to Electronic Health Records by; October 1, 2012, Lost $ 5,000 per physician October 1, 2013, Lost $ 20,000 per physician October 1, 2014, Loss of $ 44,000 per physician January 1, 2015, Penalties Start 13 If you are a Medicare Fee-for Service providers and cannot successfully demonstrate meaningful use, youwill have reduced bonus payment each year. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

37. What if you fail to meet MU by October 2014? Penalties (“adjustments”) will be applied as a percent of Medicare Part B Professional Fee Schedule Charges. They are scheduled to begin in 2015, and continue as follows: 13 2015: -1% 2016: -2% 2017: -3% 2018: -4% 2019: -5% All at the discretion of the secretary of HHS You are at risk for adjustments whether of not you received incentive payments Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

38. Potential Practice Loss of Income If you are not participating and fully electronic by October 2014; Loss of $44,000 per physician, Meaningful use. -1% Net Medicare revenue, meaningful use. -1.5% Net Medicare revenue, PQRS. -1% Net Medicare revenue, e-prescribe. Cost of ~$50,000, conversion to ICD 10. 13 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

39. Hospital-based, 300 patients/year. Twofull time Rad. oncology physicians. Meaningful use bonus $.............$-88,000 Meaningful use…………….…...$-6,350 PQRS…………………………..…$-9,525 E-prescribe………………..……...$-6,350 Estimated Total loss to practice $-110,225 Add ICD 10…..……………….... $-50,000 NIB Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

40. Freestanding center, 300 patients/year, Two full time Rad. oncology physicians. Meaningful use bonus $..............$-88,000 Meaningful use………………….$-42,000 PQRS...............................................$-63,000 E-prescribe……………………….$-42,000 Estimated Total loss to practice$-235,000 Add ICD-10…………………….... $-50,000 NIB Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

41. Meaningful Use 2010, The first year 1% of US physicians met the Meaningful Use requirements ($72 Million) 2011, 8,401 physicians received the $18,000 bonus payment. ($150 million) (2.1%) 2012, 55,000 physicians received incentives. (Over $1Billion) (13.7%) 2013, Estimated 96,000 physicians will receive incentive bonus, ($1.67 billion)(23.9%) There are 440,000 eligible physicians in the US (~$ 20 Billion available to pay out) NIB Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

42. Some of The reasons cited are: The high cost of implementation of an electronic health record. Time commitments from everyone involved to make the changeover. No one wants to learn a new computer program. I thought I was exempt from meaningful use. I did not know that meaningful use was required for my practice. I did not even know such a program existed. NIB Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

43. 13 Hospitals are also eligible for big incentive payments if they make meaningful use of their EHR Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

44. Before you purchase any EHR program, be certain the vendor can meet the time table and requirements for meaningful use. 14 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

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46. Does the EMR cause a negative impact on your workflow? NIB Are extra steps needed for MU? Vitals collection is part of normal workflow – not added on as an extra task Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

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