Device technology is always on the move in the orthotics and prosthetics business, providing more options for patients and clinicians. Technological advancements in recordkeeping software can help clinicians stay on track of appointments, reminders, billing, coding and inventory. Within this software, electronic health records — also known as electronic medical records — can be an easier, more efficient way to keep up with patients’ medical history.
“The medical field seems to be outdated. It’s the only field that hasn’t been computerized, so it still uses antiquated paper records. It’s not surprising that there is now a push to adopt electronic health record systems,” Sharona Hoffman, JD, professor of law and bioethics and Edgar A. Hahn professor of jurisprudence at Case Western Reserve University School of Law, told O&P Business News.
Paper charts vs. EHR system
Unlike EHR systems mainly used for medical practices, EHR systems specifically made for O&P business use, such as Futura International and OPIE, have clinical enhancements in addition to a billing system, which makes it easier to keep everything in one place. However, many O&P businesses still use paper charts instead of an EHR system, especially smaller, one location businesses.
“I’m not sure if the O&P industry has conformed to using EHR systems yet,” Jeffrey Brandt, CPO, president of Ability P&O, told O&P Business News. “I feel like there’s still a bit of resistance out there and I don’t know if the people who do use an EHR system have completely given themselves up to it.”
According to the North Carolina Healthcare Information and Communication Alliance Inc., there are several advantages with EHRs, including quick retrieval of and easier access to more complete patient information. Time stamping allows practitioners to see the kind of care a patient received and when, and what follow-up is required. Accessing patient records on the road is easier if the EHR system is paperless.
“There is a good deal of O&P that is done on the road, and I think that is another huge plus for EHRs. It really makes seeing patients on the go easy because you’re not carting paperwork around,” Brandt said. “With an EHR you produce paper when you need to, thereby reducing the risk of losing it. I explain to practitioners that their computer is their workstation. Twenty papers sitting around your desk does not mean production any more.”
EHRs can send reminders about scheduled tests, allow practitioners to look at all test results during a 5-year period and establish better profiles of each patient’s health. Hoffman added that EHRs can save time, allowing physicians to send orders electronically to the lab or pharmacy and eliminating filing and mailing.
“[EHRs] generally have alerts and reminders that can provide life-saving information, such as allergies or drug-drug interactions,” Hoffman, who is also the co-director of the Law Medicine Center, said. “Not only can that benefit patients, but it can also save costs because physicians can avoid costly errors that may require lengthy hospitalization.”
Although the alerts and reminders can save money by preventing hospitalization, some physicians complain that they are often distracting or about trivial things that do not apply to a particular patient. Many physicians turn the feature off, which may cause them to miss critical alerts and reminders, giving rise to malpractice liability concerns.
Physicians also complain that some EHR systems are not easy to navigate and inputting information takes longer because the computer program demands input of a lot of information that previously was not recorded in paper charts. It is also easy to make mistakes, such as inverting numbers or typing information into the wrong patient record.
“Implementing an EHR doesn’t solve all problems,” Hoffman said. “It might eliminate some problems, but, as with any new technology, it also creates new problems.”
“Our industry has been so device-centric,” Brandt said. “We’re always worried about the leg and the brace, which is important, but I think EHRs have brought with it to O&P this sense of patient management. The idea that, yes, we provide a device, but we are also very much responsible for the management and the documentation of that patient’s care and I think that’s more in the forefront now than it ever has been in our industry.”
General auditing issues
If a practice with an EHR system is audited, several problems can occur if information is not input into the system correctly. According to Melody Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS, owner of Career Coders, LLC, cutting and pasting, grey areas, chronic problems and medical necessity can cause obstacles when auditing electronic records.
“Some of the problems that we find when we audit is if information is incorrect in any way, then whoever copied that information has no way of knowing that the information is incorrect,” Irvine said. “If the information is corrected, then other people who may have downloaded the information previously might not have the updated information.”
According to the Office of Inspector General, “Medicare contractors have noted an increased frequency of medical records with identical documentation across services,” which is usually caused when patient information is copied and pasted into the system. Without reading over what information is being provided, a clinician could be entering wrong or repetitive information, which could lead to malpractice and fraud issues.
The Department of Health and Human Services (HHS) released a bulletin in September that addressed the issue of cut and paste: “A patient’s care information must be verified individually to ensure accuracy: it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments.” The government is taking a firm stand on this issue and this will be pursued aggressively by the HHS.
Grey areas are also problem areas because certain terms do not have exact definitions for every practice, which could cause confusion in sharing patient information across different types of practices, for example, between a physician and an O&P practitioner.
“Our computers are not human brains, so we have to make sure that it’s set up correctly in the templates to accept terminology and wording that would be acceptable for our Medicare contractors,” Irvine said.
Finally, chronic problems and medical necessity may cause problems when it comes to listing the level of Medical Decision Making (MDM) for the patient. According to Irvine, “Counting a chronic problem that is not relevant or addressed in that day’s encounter could give a higher level of MDM. This could be a problem due to, and considered fraud by, upcoding the level of visit. Unless the chronic problem is secondary to the condition, it cannot be a valid diagnosis for the encounter.”
Irvine recommended that clinicians and physicians alike have an auditing compliance plan. “We have regular compliance plans, but auditing compliance plans set the guidelines for how everything will be viewed for their auditing purposes,” Irvine said. “I also think building and having a good team of people to put together your EHR system is very important.”
Providing O&P EHR software since 1994, Futura International is one of the oldest providers of O&P-specific EHR systems in the United States. Since then, Futura has evolved to include anti-theft electronic claims, automatic claims posting, digital signatures, electronic justification notification and a number of clinical data forms that are specific to the O&P industry that output to Microsoft Word for user customization to the physician or other referral source.
“We specialize in dealing strongly with accounting systems and have the ability to interface with QuickBooks, GreatPlains and some of the other larger accounting systems so that an O&P practice of any size, whether it’s a three-person operation or a 3,000-person operation, will be able to operate their business and get what they need out of the EHR system,” Marshall Fryman, president of Futura International, said.
For auditing help, Futura provides an auto-tracking system. When an item has been closed, the EHR system continues to keep track of updates, such as who made the last modification and when and if anything has changed since then. According to Fryman, there is a revision coming out called Flex Audit, which is more of a clinical auditing system where clinicians can receive alerts and sign off on rules based on patient data. For example, if Medicare requires Medicare compliant prescriptions, the software will not pick up on that rule. Instead, an employee can sign off in the system that they read the prescription and that it is Medicare compliant.
“The revision is fairly new, but it’s going to be very powerful in terms of how it drives compliance and helps companies maintain compliance with the evolving standards,” Fryman said.
One special feature of Futura’s EHR system is the delivery mechanism that allows a company’s EHR system to connect to Futura’s data center where their information will be stored and automatically updated.
“We have all the backup functionalities in two or three data centers with automated replication so that even if something happened to a data center the system would simply connect into a different data center automatically and the company would still have all their information,” Fryman said. “This is the way all of the EHR systems will be going as we see more and more reliance on being mobile and less on being in the office.”
When Paul E. Prusakowski, CPO, FAAOP, president and chief executive officer of OPIE, created the system in 1999, he had a vision of where the software would take the O&P business.
“When I started my own practice I had a vision of how future practices should run with point to patient care EHR systems and workflow management software that tied all aspects of clinical care and coordination of processes and people together,” Prusakowski told O&P Business News.
According to Prusakowski, compared with O&P business billing software that includes features that allow practitioners to place notes and take measurements, OPIE was created as a standalone EHR system before the billing module was built in.
“OPIE was started at the very beginning with the medical record and the workflow management as the core of the software and that’s really what differentiates us,” he said.
Designed by and for clinicians, OPIE can be used internationally and anywhere a clinician goes with the help of the mobile application. Notable features include the in-person workshops and boot camps for administrative staff, clinicians and billing staff to keep everyone up to date with changes in policy, giving tips on how to make changes in their practice and to keep the EHR system in compliance.
“OPIE is not just a replacement to traditional billing software, but a complete overhaul of the way a practice is going to run. The practices that have made the leap have seen significant improvement in accountability, work flow management, reportability and significant improvements in their documentation standards.”
CMS incentive program
The Health Information Technology for Economic and Clinical Health (HITECH) Act was created to help implement EHR use among physicians, health care professionals and hospitals by rewarding eligible professionals, hospitals and critical access hospitals (CAHs) with Medicare and Medicaid incentive payments when they adopt and meaningfully use certified electronic health record (EHR) technology. Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program and up to $63,750 through the Medicaid EHR Incentive Program.
Stage 1 began in 2011 and established objectives that providers had to achieve in order to demonstrate meaningful use. Eligible professionals have to meet 15 core objectives and five menu objectives that they select from a list of 10. Eligible hospitals and CAHs have to meet 14 core objectives and five menu objectives that they select from a list of 10. Meaningful use must be demonstrated during a 90-day EHR reporting period in the first year of participation, followed by a full year of meaningful use in subsequent years, except in 2014 when all providers are only required to demonstrate meaningful use for a 3-month EHR reporting period regardless of their stage of meaningful use.
In August, the Centers for Medicare & Medicaid (CMS) and Office of the National Coordinator for Health IT released final requirements for stage 2 of the HITECH Act. These requirements include steps that hospitals and health care providers must meet in order to qualify for Medicare and Medicaid incentive payments during the second stage of the program, as well as criteria that electronic health records must meet to achieve certification. According to a press release, beginning as early as 2014, stage 2 of the program will increase health information exchange between providers and promote patient engagement by giving patients secure online access to their health information. Stage 3 of the program will begin in 2016 and continue to expand meaningful use objectives to improve health care outcomes.
According to the CMS website, any Medicare eligible professionals, hospitals and CAHs that are not meaningful users of an EHR technology under the Medicare EHR Incentive programs will incur payment adjustments. Payment adjustments will be applied beginning on Jan. 1, 2015 for Medicare eligible professionals, on Oct. 1, 2014, for Medicare eligible hospitals and beginning with the fiscal year 2015 cost reporting period for CAHs. However, eligible professionals, hospitals or CAHs that can only participate in the Medicaid EHR Incentive Program and do not bill Medicare are not subject to these payment adjustments.
Any eligible professional, eligible hospital or CAH could potentially be subject to an audit if they attest to receive an EHR incentive payment for either the Medicare or Medicaid EHR Incentive Program. According to CMS, “There are numerous ways to select a specific eligible professional or hospital for audit; random selection is one approach. There are also numerous pre-payment edit checks built into the EHR Incentive Programs’ systems to detect inaccuracies in eligibility, reporting, and payment. Post-payment audits will also be completed during the course of the EHR Incentive Programs. If, based on an audit, a provider is found to not be eligible for an EHR incentive payment, the payment will be recovered.”
At this time, O&P practices are not included in the CMS incentive program. However pedorthic practices can qualify and can participate in the incentive program provided they use an approved EHR system.
Meaningful use requirements are limited to Medicare Part A providers.
To be eligible for the CMS incentive program, a provider must use an EHR system that is certified by the HHS Office of the National Coordinator for Health IT. — by Casey Murphy
Disclosure: Fryman is employed by Futura International. Prusakowski is the creator of OPIE. Hoffman and Irvine have no relevant financial disclosures.Disclosure: O&P Business News does not endorse any company or products mentioned herein. Not all companies or products relevant to the topic are represented.