The Quality Payment Program in 2019: What to Know About Upgrading Your EHR

Dr. Johnson:
As physicians are learning more about MACRA, the Quality Payment Program, and other initiatives central to quality reporting transitions, the question of where electronic health record systems fit into all of this comes up often.  This is a critical window for updating our EHRs to participate in MACRA moving forward.  But which EHRs will get us there, and when? 

This is Inside Medicare’s New Payment System on ReachMD, and I’m Dr. Shira Johnson.  Joining me from the American Medical Association are Matt Reid, Senior Health IT Consultant, and Laura Hoffman, Assistant Director of Federal Affairs.  We will be discussing what physicians need to know about switching or upgrading EHRs to make quality reporting more successful in practice. 

Laura and Matt, welcome to the program. 

Ms. Hoffman:
Thank you for having us. 

Mr. Reid:
Thank you. 

Dr. Johnson:
So, to start, let’s get a better sense of your respective roles at the AMA and how they intersect with this objective to help physicians upgrade their EHRs.  Laura, let’s start with you. 

Ms. Hoffman:
Thanks.  Well, my background is in public health and health law, but I currently work on healthcare policy, particularly health IT and privacy and security matters, and I work closely with Matt to convey physicians’ needs with respect to health IT to the Federal Government in hopes of improving physicians’ and patients’ experiences when interacting with health IT, including when sufficient to upgrade their EHRs. 

Dr. Johnson:
And, Matt, can you tell us a little about your background? 

Mr. Reid:
Yeah, sure.  Thank you.  I echo everything Laura just said.  My background is in health IT implementation.  I have experience in managing large medical practices and have a bit more focus on the medical informatics side of the equation.  So Laura and I complement each other.  She’s very policy focused, I’m more of a subject matter expert on technology, so that’s how we both address these very important issues for physicians. 

Dr. Johnson:
Good, sounds like you’re a good team.  Thank you both.  Laura, can you provide our listeners just a little background on the Quality Payment Program so that we’re all on the same page? 

Ms. Hoffman:
Absolutely, but fair warning, get ready for a handful of acronyms most programs have in Washington.  So to get started, in 2016, the Centers for Medicare and Medicaid Services, which is also known as CMS, developed regulations to implement the Medicare Access and CHIP Reauthorization Act, or MACRA for short.  This historic Medicare reform law repealed the Sustainable Growth Rate formula and created the Quality Payment Program, or the QPP.  The QPP is comprised of 2 new payment pathways for physicians:  Alternative Payment Models, also known as APMs, and the Merit-Based Incentive Payment System, or MIPS.  In our conversation today, we’ll be focusing on the MIPS pathway in which CMS anticipates that most physicians will participate right now.  Many physicians already have participated in Medicare reporting programs in the past, which they’ll be more familiar, such as the Physician Quality Reporting System, or PQRS, the Value-based Modifier, or VBM program, and the Meaningful Use Program, but under the QPP, these programs have been consolidated and streamlined into MIPS. 

Dr. Johnson:
So on that last note, Laura, what more should we know about MIPS? 

Ms. Hoffman:
Well, MIPS is comprised of 4 components.  Many of them are replacing what I just mentioned.  So there’s quality, which replaces the PQRS program; there’s cost, which replaces the Value-based Modifier, or VBM; and then Advancing Care Information, which replaces Meaningful Use; and finally, Improvement Activities, which is a brand new component.  So, while it’s not necessary to use an EHR to successfully participate in MIPS, doing so will help to maximize your success. 

Dr. Johnson:
And I understand that there are some coming changes to MIPS that will require many physicians to upgrade their current EHRs.  Can you address that? 

Ms. Hoffman:
Yes.  So most of the listeners who have already participated in the Meaningful Use Program, they are more than likely using 2014 edition EHRs, and these products have been around for a while.  They were certified by the Federal Government for use for Meaningful Stages— Meaningful Use Stages 2 and 3 and can be used for participation in the 2018 QPP performance year.  However, if you’re expecting to use an EHR to participate in MIPS next year, in 2019, you’ll need to update your EHR to the 2015 edition version. 

Dr. Johnson:
So then, Matt, let me turn to you on the health IT side for addressing what physicians need to know or even what they need to ask about this process from a technical level. 

Mr. Reid:
The first thing we need to know is that we’re just now starting to see EHR vendors making 2015 edition EHRs available.  Based on AMA’s advocacy efforts, we were successful in delaying CMS’s requirement that would have forced physicians to adopt 2015 edition in 2018.  We did this basically because there are very few EHR vendors that had their 2015 edition products certified or be available for physicians to adopt this year.  In addition, we told CMS that forcing physicians to upgrade too soon would have caused major issues, such as forcing physicians to choose from a small number of available products or selecting an EHR that wasn’t a good fit for their practice.  CMS recognized this and pushed the requirement for physicians to upgrade until 2019, so next year. 

A handful of the largest EHR vendors have already made 2015 edition products available to their customers.  To find out if you already have a 2015 edition EHR, make sure you ask your practice administrator or check with the EHR’s customer service representative.  If you’ve already got a 2015 edition, then you’re already ahead of the game.  If not, we expect many EHR vendors to have these EHRs available later this year.  For those practices that are still using 2014 edition software, which will be most physicians, I imagine, you should check with your EHR vendors to see when they expect to upgrade your practice’s EHR to the 2015 edition.  Some vendors may tell you that they’re going through the certification requirements now and the products will be verified by the end of the year.  While this may not be necessarily a problem, be sure to ask your vendor for a timeline of when the product will be certified. 

Dr. Johnson:
Thanks, Matt.  It sounds like some EHRs are already 2015 edition ready, but most physicians will need to upgrade before 2019.  So, how should physicians prepare for this upgrade? 

Mr. Reid:
Preparation depends on a number of things, including how your current EHR is managed.  For example, many EHRs today run on a server that’s located in the physician’s office.  If your EHR software is on a server in your office, you’ll need to work very closely with your EHR vendor on the rollout of the 2015 edition.  New software requirements almost always require some level of customization, both on the EHR server or on the computers that physicians use to chart records.  Remember that some of the EHRs also run your practice management system, so that software will also need to be upgraded. 

Now, if your EHR is hosted somewhere else like in a computer data center or local hospital or even by the EHR vendor itself, you’ll need to work with the organization that manages that EHR at that location.  This may require more planning as your copy of the EHR software may be running on computers that also handle many other medical offices, so coordinating a switchover is very important here.  You should consider asking how an EHR upgrade may affect the security, stability or performance of your computer system. 

It’s also possible that your EHR vendor provides your EHR over the Internet.  This is typically known as hosting, the Cloud, or software as a service.  In this case the vendor makes changes and updates EHR software at their data center and all the customers get new versions at the same time.  It’s similar to when you would update an app on your phone, and the look and feel is different when you use it again. 

No matter how your EHR is managed, it’s very important that you have a clear timeline for switching over from 2014 to 2015 editions.  We’re expecting a fair number of changes in the way your EHR functions and operates, such as patients may be able to use apps to access their records from the EHR. 

Dr. Johnson:
Certainly it sounds like coordinating this upgrade with one’s EHR vendor is going to be pretty important, but do physicians also need to think about how this upgrade will affect their computers and their networks? 

Mr. Reid:
Yes, an upgrade from the 2014 to 2015 edition may require upgrades of their EHR server hardware and operating system.  You may need to make additional changes depending on how you connect the EHR to the outside world.  For instance, many physicians connect their EHRs to local health information exchanges or clinical data registries.  These connections are typically customized and unique to your own medical office.  An upgrade to your EHR requires that these connections are tested, and in some instances the health information exchange or clinical registry must coordinate with your EHR vendor on the upgrade.  The personal computers in your medical office may also need to be upgraded.  This would include those in the back office, the check-in desk, and those used in the clinic.  The 2015 edition may require more current hardware or software that’s being currently used in your office.  As we discussed before, part of your EHR vendor’s timeline for getting you the 2015 edition software should include what, if any, are the new system requirements. 

Additionally, this type of upgrade will constitute a major change to your network’s infrastructure.  This is important, because under HIPAA, physicians must conduct a risk assessment.  While it’s typical to do a risk assessment once a year, changes in your EHR, since it’s the primary application that manages your patients’ protected medical information, requires that a medical practice go through a formal reevaluation of the privacy and security protocols and policies in place to protect electronic protected health information.  Not only is this a federal requirement, but it’s also a good practice.  A risk assessment is an important step in helping protect the medical practice from cyber threats.  The AMA has a few tips and tricks to help you get going, and our website www.AMA-assn.org/cybersecurity also links to free resources that can help conduct a risk assessment. 

Dr. Johnson:
So if we look at this upgrade holistically from the standpoint of how it’s going to impact not only one physician’s EHR but really the entire medical practice, how will costs and training efforts play into this transition? 

Mr. Reid:
That’s a great question.  Cost is definitely something that will differ by age or vendor.  This could range from a no-charge update all the way to multiple software and service fees.  There’s also consideration of hardware and third-party costs in order to support switching from the 2014 to 2015 edition EHR.  I suggest the first thing physicians do is examine the contract you sign with your EHR vendor.  On top of the original purchase price of the EHR, vendors also charge monthly service fees.  In my experience many of these monthly fees cover the cost of the upgrades, and I’d start there.  If your EHR is hosted by another organization or by the EHR vendor, the upgrade may be part of the normal maintenance cost you’re already paying for.  For those who encounter unexpected fees from the current vendor, I’d suggest thinking about other products that you may want to migrate to.  This is an extreme approach, but if you’re already considering going through all the work for this type of upgrade and your EHR vendor is unwilling to work with you on the cost, it may be a good time to look at another product or option.  Just make sure you also include the cost and time to migrate to another EHR into that equation.  Like I said, it’s a big lift, but it might be worth it. 

Dr. Johnson:
What about training?  Is that going to affect the rollout of the 2015 edition EHR? 

Mr. Reid:
As far as training, you definitely want to carve out time to learn about new features and changes.  2015 edition updates will impact higher EHR functions and will add new features you may not have already had in the past.  This includes changes to your EHR’s exchange in patient records or the interoperability of medical information.  There may be also new dashboards or reporting tools to help you comply with CMS or other payer requirements.  In addition, your patients will have the ability to now use applications, or apps, to access their record.  This is one of the biggest changes and may require a great deal of education for you, your staff and your patients.  I suggest reaching out to your vendor to learn about how these apps work and what you should talk to your patients about as they start to use these apps. 

Many EHR vendors offer differing levels of training.  This can range from simple written materials that outline the difference between EHR versions all the way to on-site training packages.  Depending on your comfort level and financial resources, you may want to consider a hybrid approach.  One possible option is using an online training module or prerecorded training webinars in conjunction with live, remote training classes that are conducted by your vendor; like training done over the Internet is typically more cost-effective while still providing you with the opportunity to ask questions and see how your EHR will function before you even have it installed.  No matter which path you take, training is very important.  Not only does it help you get accustomed to the new look and feel of your EHR, but you may also learn about current features you’re not even aware of. 

For more on how to choose an EHR or for a detailed overview of how to implement an EHR, the AMA has created 2 STEPS Forward modules to help you out.  Go to www.STEPSForward.org to search for your EHR. 

Dr. Johnson:
Well, Matt and Laura, it certainly sounds like a successful EHR migration will require a lot of coordination, planning and preparation, but the upsides are new features and functions that can really benefit both physicians and patients and encourage their interaction in a way that’s compliance forward.  So, one last question:  Are there any other takeaways you want to impart to our audience today? 

Ms. Hoffman:
Well, first, I agree with how you’ve just categorized the upgrade.  It involves some work, but there are upsides to an upgraded system, including new ways for patients to access their medical information and enhance interoperability features, and by no coincidence, these are both priority policy areas for CMS.  So we’ll continue to work with the Federal Government to ensure the EHRs are helpful to physicians as they practice medicine and as they participate in MIPS in 2019 and the following years. 

Dr. Johnson:
So, Laura Hoffman and Matt Reid, thank you both for joining the program today, and it’s really good for our listeners knowing that with this program rolling forward, the AMA is providing a lot of support both online and other ways that they can reach out to the vendors with their EHRs and make sure that they are compliance-ready going forward.  Thank you very much, Laura and Matt, for joining the program today. 

Ms. Hoffman:
Thanks so much. 

Mr. Reid:
Thank you. 

Dr. Johnson:
I’m Dr. Shira Johnson for ReachMD.  To download this podcast or others in the series, visit ReachMD.com/AMAReachMD.com/AMA.  And as always, we welcome your comments and your feedback.