It is not news to anyone in the healthcare industry that payment is continuing and that there is an increasing migration from fee-for-service to fee-for-value. Fee-for-value usually encompasses some combination of cost and quality. In the commercial market especially, HEDIS metrics are often the primary focus of quality measurement. Such metrics are often preventative measures that involve targeted actions at specific populations. It is often the case that most practices are not maximizing their revenue by optimizing their quality/incentive processes and making optimal use of their EMR and its reporting functions.

Prior to discussing some strategies to effectively use one’s EMR to close more HEDIS gaps, it is important to recognize that regardless of how well thought out and accurate one’s EMR processes are, if that data is not making it to the payer, than it is irrelevant from an incentive perspective. The most straight-forward method of getting data to a payer is by attaching it to a claim. Wherever possible, a practice’s billers should put forth the effort to attach such informational data to claims so that it is processed by the payer. Administrative or claims data is the easiest data to use for HEDIS as it does not have as much of an additional audit threshold as does supplemental and non-standard supplemental data (the other ways to enter data). If one’s payer – for some reason – does not allow such data, they may very well have a portal that can be used to enter such data. An audit may be required but is likely relatively straightforward. While this may seem duplicative – charting in an EMR and then in a data entry tool – the financial benefits may outweigh the staffing costs. The final way is through a feed from one’s EMR to the payer; this is an efficient method, but it is not always available. Practices that are part of an IPA or ACO are more likely to have this available as it is may be a part of any extensive risk-based payer contract.

Within the practice, however, the first step that must occur is to have an agreed upon method for charting data related to measures. If your EMR has a HEDIS module, their guidance is likely best to be used because they can calculate quality measure numerators and denominators and probably provide additional reporting tools. If there isn’t a HEDIS module, one is fortunate because a lot of HEDIS measures are fairly straightforward. For example, A1C screenings for diabetics, BMI screenings, and blood pressure screenings are simple enough; however, there are more challenges for measures such as retinal eye exams for diabetics and depression screenings. If one doesn’t have an EMR with a PHQ2/9 form and scoring tool, one must convert a paper version of the form – at least the final score – into some sort of electronic notation in the chart and with the retinal eye exam, one must convert the findings (date of the exam and positive/negative for retinopathy) from the referral note. Often there are structured data fields that can be created or templates that can be used for such information. What is important to be mindful of is if one’s EMR has a generic reporting/registry tool, the recording of such measurement information should be done in a way that can be reported by with such tools (examples include eClinicalWorks’s registry and EBO reporting tools).

Once a practice has determined a documentation strategy, the processes must be put in place. For example, during chart prep, staff ought to check to see what gaps the patient has. That can be done by either referencing an internal EMR registry or – if available – looking up the patient on a payer portal. To make things more efficient, if the provider is needed, such requests should be documented in a standard area that is check during every visit. Also, at regular intervals staff should pull lists of patients in need of gap closure (e.g., patients that need colorectal cancer screenings) and contact them via a messaging service built into the EMR, the patient portal, phone calls, or all three in order to be sure that needed services are performed. Practices may decide to concentrate on one or two measure per month for example. What is important is to have a methodical, regular, and consistent process that ensures that patients are tracked for compliance with HEDIS measures and contacted appropriately. Patients that persistently have large numbers of care gaps may be candidates for care management; sometimes care managers are more successful than other staff members at bringing a particular patient into optimal compliance.

It is important to remember that recording data in one’s EMR is not the goal; it is only a tool. The data must be tracked and sent somehow to the payer at regular intervals to optimize incentives and to allow a provider to demonstrate their effectiveness as a healthcare provider. One should look first to send the data through claims, then through an EMR interface if possible, and – finally – by entering the data into a payer portal.

Categories: Healthcare IT


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