By Jim Grue, OD,
Ronald P. Snyder, OD, FAAO,
and Michael J. Lipson, OD, FAAO, FSLS
July 13, 2022
Until now, no one outside of your practice has been able to view your patient records in your EHR. When you sent letters or faxes to other providers, it was you and only you who decided what to include in your communications.
Previously, when payors audited your charts, they only looked to see what tests you performed. No one outside of your practice knew if there were omissions, inaccuracies or contradictory information in the exam results that you recorded.
That all changes with the information blocking rules established by the 21st Century Cures Act. Every vendor of a certified EHR is required by December 31, 2022, to have in place a FHIR endpoint server (click HERE for an example of how a FHIR service works).
The new “FHIR” standard defines how healthcare information is to be exchanged between different computer systems. This standard is designed to give access to all of your exam data to any outside organization that has been authorized by your patient. FHIR also provides payors with complete access to your data. FHIR is a computer standard referred to as a “pull system.” That means that any authorized party can log into your EHR and “pull” data without requesting or notifying you.
If either you or your EHR vendor blocks this access, it will be considered information blocking. You may be subject to potential disciplinary action, and your EHR vendor to financial penalties. There are extensive security provisions around FHIR to protect patient health information while still allowing the data to be where it is needed when it is needed.
Now may be the time for you to take a serious look at how data is recorded in your exams. Your omissions, inaccuracies and contradictory information will now be seen by other providers, patients and other organizations. This may not reflect well on the image of your practice.
One of the most significant implications of the information blocking rules is that payors will now have complete access to your exam records. Previously, payor audits were performed by individuals with relatively little training that simply looked to see if specific things were completed. Payors will now use the power of big data analytics to conduct audits. This will allow them to create analytics that will show them the quality of the exams that you have performed. Healthcare Registries is leading our profession in anticipating what type of analytics payors will likely be interested in. Think tank-style groups have concluded that payors will likely examine three different categories of analytics:
1. Quality Indicator Analytics
2. How successfully your practice has transitioned to an outcome-based, patient-centered and coordinated care delivery model.
3. Whether you have met the required reporting requirements for mandatory post-op co-managed cataract surgery reports, or the required reports that are to be sent to the primary care provider following a diabetic annual eye exam.
The second and third category will be discussed in a future article. For now, let’s concentrate on what quality indicator analytics may look like.
Payors will likely look for quality indicators in three main components of a typical annual eye exam:
This will help the payor understand how much effort you put into understanding the overall health of the patient before the exam even starts. Since payors expect that the exam will assess ocular side effects of any health conditions the patient may have, it seems reasonable that they will look to make sure that chronic conditions the patient has are documented in your patient Problem List. Everyone would expect them to see if diabetes is documented, but in addition, the diagnosis of hypertension is probably a better analytics indicator of quality. If hypertension isn’t documented in the Problem List, what are the chances the ocular side effects were properly assessed? If hypertension is documented, then most likely other significant health conditions will be also.
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This may be of high interest to payors as the external eye exam is designed to look for significant neurological and medical problems. Missing these diagnoses increases the risk to payors. Anisocoria may be one the best indicators of quality. An accurate measurement of pupil size difference requires accurate instrumentation, and is reported to exist in 20 percent of the population. Evaluating the pupils for the presence of anisocoria with a swinging flashlight test identifies anisocoria about 3-5 percent of the time. Best practice literature strongly supports documenting and diagnosing anisocoria when present. From a payer’s standpoint, what is their confidence level that a significant pupil abnormality, for example, Horner’s pupil, will be identified if anisocoria is not regularly diagnosed?
If payors look for hypertension in the Problem List, then looking for the percentage of time that hypertensive retinopathy is diagnosed is a logical analytic for the internal exam. The incidence of hypertensive retinopathy among hypertensive patients is well documented in the literature. If your exam doesn’t consistently find a diagnosis of hypertensive retinopathy in the expected frequency, payors will not have confidence that you will find other vascular and retinal abnormalities. Best practice literature clearly indicates hypertensive retinopathy needs to be shared with the rest of the patient’s healthcare team as it is potentially one of the indicators used by physicians to decide whether better control is needed.
Healthcare Registries monitors these analytics for those practitioners who are making a serious effort to prepare for outcome-based care. Our registry data shows two interesting trends: The first trend is that those practitioners who haven’t yet transitioned to the type of outcome-driven care that healthcare reform is putting in place, perform poorly on at least two of these measures. The second trend of interest is the practices that are making the transition to outcome-based care tend to perform well on these measures.
In fact, practices that initially performed poorly, but which have begun the transformation process, not only quickly improve their analytics, but are now preparing their practices to actively engage in the next level of outcome-based, patient-centered, coordinated care that payors want to see. Analytics that guide this transition will also be addressed in a future article.
How to Improve Your Analytics
If you decide that you want to improve the data you are recording in your EHR, the process is surprisingly simple. In fact, you will find these features will significantly reduce the burden on both you as a provider and your staff.
The steps to improve each of the three measures:
For the first measure, include hypertension in the Problem List. The easiest way to do that is by signing up with a service, such as Kno2 or Carequality, to retrieve “an exam summary” report,” known as a C-CDA, from the patient’s PCP. The C-CDA (Consolidated Clinical Document Architecture) is the most widely used format for health information exchange in the U.S. today.
Kno2 will send the C-CDA to your certified EHR’s Direct Secure Messaging inbox. From there, your certified EHR already has the ability to extract information such as the patient Problem List, medication list, etc., and place it into your exam workflow. To see how to access a CCDA and embed it your workflow, logon to www.HealthCareRegistries.com. Click the “Resources” link and then click “Videos” and watch the video entitled “Importing a CCDA from Direct Messaging.”
For the second measure, the percentage of patients with a diagnosis of anisocoria, the assumption is that you or your technician are already doing a thorough pupil evaluation. A check of multiple EHRs indicates that most included a pupil evaluation check-off box with a field for anisocoria. It doesn’t take any longer to check off the box for anisocoria than it takes to check off PERRL or PERRLA. The difference is whether the diagnosis is listed in the Problem List or not. When you indicate anisocoria during your exam, if your EHR doesn’t automatically insert the diagnosis of anisocoria in your Problem List, ask your EHR vendor to add this feature. That will dramatically improve your analytics.
For the third measure, your exam should be identifying, documenting and communicating the presence of hypertensive retinopathy with the rest of the patient care team. Your exam should already be looking for it. Be sure that when you document the clinical findings, the diagnosis of hypertensive retinopathy is always added to the patients’ Problem List. If you aren’t already communicating those findings to the rest of the patient care team, you need to begin that process now. Again, that shouldn’t take any additional effort on your part. When you add a diagnosis of hypertensive retinopathy, your EHR system should automatically trigger your system to generate and send a report. Just click “YES” when your EHR confirms that you want to send the report.
The planning for information sharing began at the inception of healthcare reform. We have now reached the point where regulations will ensure that we as providers share our information with other providers, and that we also have access to important health information that other providers have in their systems.
HealthCare Registries can not only provide the analytics you need to improve the measures that payors will likely be interested in, but also provide the analytics necessary to allow you to deliver patient-centered, outcome-based care that you coordinate with the rest of the patients’ care team.
Our next article will discuss the clinical analytics that will help you through this part of the transition.
James E. Grue, OD, is a health-care reform speaker and consultant. To contact him: JimGrue@HealthCareRegistries.com
Ronald P. Snyder, OD, FAAO, is the president and CEO of HealthCare Registries, LLC. To contact him: RonSnyder@HealthCareRegistries.com
Michael J. Lipson, OD, FAAO, is the chairman of the OrthoK Advisory Panel of HealthCare Registries, LLC.