Mary Ellen Schneider

PHILADELPHIA — Physicians purchasing an electronic health record will be able to consult a list of certified products as early as this summer, according to Dr. Mark Leavitt, chair of the Certification Commission for Healthcare Information Technology.

The certification commission planned to begin accepting applications from electronic health record (EHR) vendors in late April or early May and to publish a list of certified products and their developers in late June or early July.

The list, featuring the first batch of products with the certification commission's seal of approval, will be published on its Web site (www.cchit.org

The process of certification is voluntary and its success is dependent on acceptance in the marketplace, Dr. Leavitt said at the annual meeting of the American College of Physicians. “We're not setting the bar above everyone's heads so that no products meet it,” he said. “But it is not trivial to have a product that meets the criteria.”

The certification commission was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology. In September 2005, the group received a 3-year contract from the Department of Health and Human Services to work on certification criteria for EHRs.

The certification commission is focusing first on certifying products for the ambulatory setting. In phase II, the commission will work on evaluating EHR products for the inpatient setting, and in phase III it will evaluate the infrastructure or network components for EHR interoperability.

Vendors will apply for certification and pay a testing fee. To keep costs down, the testing will be done virtually through an Internet browser. A three-person panel, including at least one practicing physician, will judge the demonstration of the product during a process that could take several hours to a day, Dr. Leavitt said.

It's unclear how many products will be certified in the first round, he added.

EHR products will be evaluated based on more than 250 functional requirements. But the commission is not in the business of designing EHRs, said Dr. Sarah T. Corley, cochair of the certification commission's functionality workgroup, and there will be some variability in the market.

The standards developed by the commission will set a baseline for what every physician needs in an EHR, but some subspecialists may need to work with vendors to add more functionality, she said.

But the commission's work should be valuable to physicians in all specialties because it will help to narrow the field, Dr. Leavitt noted. “You still need to do your homework,” he said, but certification will allow physicians to hone in on the advanced level of functionality they need.

PHILADELPHIA — Physicians purchasing an electronic health record will be able to consult a list of certified products as early as this summer, according to Dr. Mark Leavitt, chair of the Certification Commission for Healthcare Information Technology.

The certification commission planned to begin accepting applications from electronic health record (EHR) vendors in late April or early May and to publish a list of certified products and their developers in late June or early July.

The list, featuring the first batch of products with the certification commission's seal of approval, will be published on its Web site (www.cchit.org

The process of certification is voluntary and its success is dependent on acceptance in the marketplace, Dr. Leavitt said at the annual meeting of the American College of Physicians. “We're not setting the bar above everyone's heads so that no products meet it,” he said. “But it is not trivial to have a product that meets the criteria.”

The certification commission was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology. In September 2005, the group received a 3-year contract from the Department of Health and Human Services to work on certification criteria for EHRs.

The certification commission is focusing first on certifying products for the ambulatory setting. In phase II, the commission will work on evaluating EHR products for the inpatient setting, and in phase III it will evaluate the infrastructure or network components for EHR interoperability.

Vendors will apply for certification and pay a testing fee. To keep costs down, the testing will be done virtually through an Internet browser. A three-person panel, including at least one practicing physician, will judge the demonstration of the product during a process that could take several hours to a day, Dr. Leavitt said.

It's unclear how many products will be certified in the first round, he added.

EHR products will be evaluated based on more than 250 functional requirements. But the commission is not in the business of designing EHRs, said Dr. Sarah T. Corley, cochair of the certification commission's functionality workgroup, and there will be some variability in the market.

The standards developed by the commission will set a baseline for what every physician needs in an EHR, but some subspecialists may need to work with vendors to add more functionality, she said.

But the commission's work should be valuable to physicians in all specialties because it will help to narrow the field, Dr. Leavitt noted. “You still need to do your homework,” he said, but certification will allow physicians to hone in on the advanced level of functionality they need.

PHILADELPHIA — Physicians purchasing an electronic health record will be able to consult a list of certified products as early as this summer, according to Dr. Mark Leavitt, chair of the Certification Commission for Healthcare Information Technology.

The certification commission planned to begin accepting applications from electronic health record (EHR) vendors in late April or early May and to publish a list of certified products and their developers in late June or early July.

The list, featuring the first batch of products with the certification commission's seal of approval, will be published on its Web site (www.cchit.org

The process of certification is voluntary and its success is dependent on acceptance in the marketplace, Dr. Leavitt said at the annual meeting of the American College of Physicians. “We're not setting the bar above everyone's heads so that no products meet it,” he said. “But it is not trivial to have a product that meets the criteria.”

The certification commission was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society, and the National Alliance for Health Information Technology. In September 2005, the group received a 3-year contract from the Department of Health and Human Services to work on certification criteria for EHRs.

The certification commission is focusing first on certifying products for the ambulatory setting. In phase II, the commission will work on evaluating EHR products for the inpatient setting, and in phase III it will evaluate the infrastructure or network components for EHR interoperability.

Vendors will apply for certification and pay a testing fee. To keep costs down, the testing will be done virtually through an Internet browser. A three-person panel, including at least one practicing physician, will judge the demonstration of the product during a process that could take several hours to a day, Dr. Leavitt said.

It's unclear how many products will be certified in the first round, he added.

EHR products will be evaluated based on more than 250 functional requirements. But the commission is not in the business of designing EHRs, said Dr. Sarah T. Corley, cochair of the certification commission's functionality workgroup, and there will be some variability in the market.

The standards developed by the commission will set a baseline for what every physician needs in an EHR, but some subspecialists may need to work with vendors to add more functionality, she said.

But the commission's work should be valuable to physicians in all specialties because it will help to narrow the field, Dr. Leavitt noted. “You still need to do your homework,” he said, but certification will allow physicians to hone in on the advanced level of functionality they need.

More than 2 years after President Bush issued his call to action on the adoption of electronic health records, experts say there is growing pressure on physicians to heed that call.

Although physician adoption of EHRs remains low—especially in small practices—the movement toward pay for performance could start to drive adoption, said Dr. Mureen Allen, senior associate for informatics and practice improvement at the American College of Physicians. And the certification of electronic health records by an independent body, which is slated to begin this summer, should help too. “The paradigm to some extent is changing.”

This month, many of the biggest players in health information technology will gather in Washington for National Health IT Week.

More than 40 groups are slated to participate in this first-ever event, including medical professional societies such as the American Academy of Family Physicians, government agencies, a regional health information organization, and other public and private organizations.

The series of events follows on the heels of more than 2 years' major actions in the health IT landscape starting with President Bush's State of the Union address in January 2004 in which he called for the widespread adoption of interoperable EHRs within the decade.

A few months later, the Health and Human Services secretary appointed Dr. David J. Brailer as the first National Health Information Technology Coordinator. Dr. Brailer resigned from the post last month, saying that he only planned to stay in the job for 2 years.

Dr. Brailer said there is still much work to be done in closing the adoption gap between large and small physician practices. His office has been focused on three strategies to close the gap—lowering costs, raising the benefits, and lowering the risks involved in purchasing an EHR system, he said during a teleconference announcing his resignation.

Last fall, HHS Secretary Mike Leavitt established the American Health Information Community, a federally chartered commission to advise the secretary on interoperability issues. HHS proposed allowing hospitals and other entities to give physicians health IT hardware, software, and training.

HHS also awarded three contracts to public and private groups to create processes for harmonizing information standards, certifying health IT products, and addressing variations in state laws on privacy and security practices.

And starting in January, prescription drug plans participating in the Medicare Part D program were required to begin supporting electronic prescribing. The regulation is optional for physicians and pharmacies.

Most recently, the Food and Drug Administration adopted the Systematized Nomenclature of Medicine (SNOMED) standard as the format for the highlights section of prescription drug labeling. The format will be required starting on June 30 for all new drugs and drugs approved within the last 5 years.

The use of the SNOMED standards will make it easier for electronic systems to exchange FDA-approved labeling information, according to the agency.

One of the most significant developments has been the establishment of the Certification Commission on Health Information Technology (CCHIT). This group was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society (HIMSS), and the National Alliance for Health Information Technology to develop criteria for the certification of EHRs.

CCHIT received a 3-year grant from HHS last fall to certify products in the ambulatory and inpatient settings, and to certify the systems' networks. The announcement of the first certified products in the ambulatory setting is expected in late June or early July.

The means for objectively comparing EHR systems is “about to become a reality,” said CCHIT Chair Dr. Mark Leavitt.

Current estimates put physician adoption of EHRs at around 14%. Dr. Leavitt said he hopes that taking some of the risk out of buying an EHR product will boost those adoption figures.

“I think we are on track,” said Dave Roberts, vice president of government relations at HIMSS.

Although physicians still need to be educated about the value of EHRs, there are some other encouraging signs. For example, many states are becoming more interested in health IT and are helping to form regional health information organizations, he said.

These groups, called RHIOs, help to standardize the various regulations and business policies surrounding health information exchange. The federal government has funded more than 100 of these regional projects, and more efforts, supported by private industry or state governments, are underway, according to HHS.

“The states are really buying into this whole initiative,” Mr. Roberts said.

For the majority of physicians, it just hasn't made financial sense to purchase an EHR system, Dr. Allen said. However, some physicians are beginning to see a strategic advantage in the adoption of technology. One advantage stems from regulations that encourage electronic prescribing.

EHR adoption is inevitable, Dr. Allen said, if only because so many younger physicians were trained on EHRs and it is not acceptable to them to go back to a paper system once they enter practice. And older physicians recognize that the change is coming, she said.

But Dr. Allen advised physicians that they don't need to jump into a full-blown EHR system.

Electronic prescribing systems and electronic patient registries may be easier to adopt than a full EHR system. Physicians can also purchase EHRs in a modular fashion so that they can ramp up over time, she said.

More than 2 years after President Bush issued his call to action on the adoption of electronic health records, experts say there is growing pressure on physicians to heed that call.

Although physician adoption of EHRs remains low—especially in small practices—the movement toward pay for performance could start to drive adoption, said Dr. Mureen Allen, senior associate for informatics and practice improvement at the American College of Physicians. And the certification of electronic health records by an independent body, which is slated to begin this summer, should help too. “The paradigm to some extent is changing.”

This month, many of the biggest players in health information technology will gather in Washington for National Health IT Week.

More than 40 groups are slated to participate in this first-ever event, including medical professional societies such as the American Academy of Family Physicians, government agencies, a regional health information organization, and other public and private organizations.

The series of events follows on the heels of more than 2 years' major actions in the health IT landscape starting with President Bush's State of the Union address in January 2004 in which he called for the widespread adoption of interoperable EHRs within the decade.

A few months later, the Health and Human Services secretary appointed Dr. David J. Brailer as the first National Health Information Technology Coordinator. Dr. Brailer resigned from the post last month, saying that he only planned to stay in the job for 2 years.

Dr. Brailer said there is still much work to be done in closing the adoption gap between large and small physician practices. His office has been focused on three strategies to close the gap—lowering costs, raising the benefits, and lowering the risks involved in purchasing an EHR system, he said during a teleconference announcing his resignation.

Last fall, HHS Secretary Mike Leavitt established the American Health Information Community, a federally chartered commission to advise the secretary on interoperability issues. HHS proposed allowing hospitals and other entities to give physicians health IT hardware, software, and training.

HHS also awarded three contracts to public and private groups to create processes for harmonizing information standards, certifying health IT products, and addressing variations in state laws on privacy and security practices.

And starting in January, prescription drug plans participating in the Medicare Part D program were required to begin supporting electronic prescribing. The regulation is optional for physicians and pharmacies.

Most recently, the Food and Drug Administration adopted the Systematized Nomenclature of Medicine (SNOMED) standard as the format for the highlights section of prescription drug labeling. The format will be required starting on June 30 for all new drugs and drugs approved within the last 5 years.

The use of the SNOMED standards will make it easier for electronic systems to exchange FDA-approved labeling information, according to the agency.

One of the most significant developments has been the establishment of the Certification Commission on Health Information Technology (CCHIT). This group was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society (HIMSS), and the National Alliance for Health Information Technology to develop criteria for the certification of EHRs.

CCHIT received a 3-year grant from HHS last fall to certify products in the ambulatory and inpatient settings, and to certify the systems' networks. The announcement of the first certified products in the ambulatory setting is expected in late June or early July.

The means for objectively comparing EHR systems is “about to become a reality,” said CCHIT Chair Dr. Mark Leavitt.

Current estimates put physician adoption of EHRs at around 14%. Dr. Leavitt said he hopes that taking some of the risk out of buying an EHR product will boost those adoption figures.

“I think we are on track,” said Dave Roberts, vice president of government relations at HIMSS.

Although physicians still need to be educated about the value of EHRs, there are some other encouraging signs. For example, many states are becoming more interested in health IT and are helping to form regional health information organizations, he said.

These groups, called RHIOs, help to standardize the various regulations and business policies surrounding health information exchange. The federal government has funded more than 100 of these regional projects, and more efforts, supported by private industry or state governments, are underway, according to HHS.

“The states are really buying into this whole initiative,” Mr. Roberts said.

For the majority of physicians, it just hasn't made financial sense to purchase an EHR system, Dr. Allen said. However, some physicians are beginning to see a strategic advantage in the adoption of technology. One advantage stems from regulations that encourage electronic prescribing.

EHR adoption is inevitable, Dr. Allen said, if only because so many younger physicians were trained on EHRs and it is not acceptable to them to go back to a paper system once they enter practice. And older physicians recognize that the change is coming, she said.

But Dr. Allen advised physicians that they don't need to jump into a full-blown EHR system.

Electronic prescribing systems and electronic patient registries may be easier to adopt than a full EHR system. Physicians can also purchase EHRs in a modular fashion so that they can ramp up over time, she said.

More than 2 years after President Bush issued his call to action on the adoption of electronic health records, experts say there is growing pressure on physicians to heed that call.

Although physician adoption of EHRs remains low—especially in small practices—the movement toward pay for performance could start to drive adoption, said Dr. Mureen Allen, senior associate for informatics and practice improvement at the American College of Physicians. And the certification of electronic health records by an independent body, which is slated to begin this summer, should help too. “The paradigm to some extent is changing.”

This month, many of the biggest players in health information technology will gather in Washington for National Health IT Week.

More than 40 groups are slated to participate in this first-ever event, including medical professional societies such as the American Academy of Family Physicians, government agencies, a regional health information organization, and other public and private organizations.

The series of events follows on the heels of more than 2 years' major actions in the health IT landscape starting with President Bush's State of the Union address in January 2004 in which he called for the widespread adoption of interoperable EHRs within the decade.

A few months later, the Health and Human Services secretary appointed Dr. David J. Brailer as the first National Health Information Technology Coordinator. Dr. Brailer resigned from the post last month, saying that he only planned to stay in the job for 2 years.

Dr. Brailer said there is still much work to be done in closing the adoption gap between large and small physician practices. His office has been focused on three strategies to close the gap—lowering costs, raising the benefits, and lowering the risks involved in purchasing an EHR system, he said during a teleconference announcing his resignation.

Last fall, HHS Secretary Mike Leavitt established the American Health Information Community, a federally chartered commission to advise the secretary on interoperability issues. HHS proposed allowing hospitals and other entities to give physicians health IT hardware, software, and training.

HHS also awarded three contracts to public and private groups to create processes for harmonizing information standards, certifying health IT products, and addressing variations in state laws on privacy and security practices.

And starting in January, prescription drug plans participating in the Medicare Part D program were required to begin supporting electronic prescribing. The regulation is optional for physicians and pharmacies.

Most recently, the Food and Drug Administration adopted the Systematized Nomenclature of Medicine (SNOMED) standard as the format for the highlights section of prescription drug labeling. The format will be required starting on June 30 for all new drugs and drugs approved within the last 5 years.

The use of the SNOMED standards will make it easier for electronic systems to exchange FDA-approved labeling information, according to the agency.

One of the most significant developments has been the establishment of the Certification Commission on Health Information Technology (CCHIT). This group was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society (HIMSS), and the National Alliance for Health Information Technology to develop criteria for the certification of EHRs.

CCHIT received a 3-year grant from HHS last fall to certify products in the ambulatory and inpatient settings, and to certify the systems' networks. The announcement of the first certified products in the ambulatory setting is expected in late June or early July.

The means for objectively comparing EHR systems is “about to become a reality,” said CCHIT Chair Dr. Mark Leavitt.

Current estimates put physician adoption of EHRs at around 14%. Dr. Leavitt said he hopes that taking some of the risk out of buying an EHR product will boost those adoption figures.

“I think we are on track,” said Dave Roberts, vice president of government relations at HIMSS.

Although physicians still need to be educated about the value of EHRs, there are some other encouraging signs. For example, many states are becoming more interested in health IT and are helping to form regional health information organizations, he said.

These groups, called RHIOs, help to standardize the various regulations and business policies surrounding health information exchange. The federal government has funded more than 100 of these regional projects, and more efforts, supported by private industry or state governments, are underway, according to HHS.

“The states are really buying into this whole initiative,” Mr. Roberts said.

For the majority of physicians, it just hasn't made financial sense to purchase an EHR system, Dr. Allen said. However, some physicians are beginning to see a strategic advantage in the adoption of technology. One advantage stems from regulations that encourage electronic prescribing.

EHR adoption is inevitable, Dr. Allen said, if only because so many younger physicians were trained on EHRs and it is not acceptable to them to go back to a paper system once they enter practice. And older physicians recognize that the change is coming, she said.

But Dr. Allen advised physicians that they don't need to jump into a full-blown EHR system.

Electronic prescribing systems and electronic patient registries may be easier to adopt than a full EHR system. Physicians can also purchase EHRs in a modular fashion so that they can ramp up over time, she said.

More than one-quarter of teenagers in a recent survey did not know that sexually transmitted diseases can be passed through oral sex, reported Ms. Nicole Stone, at the Centre for Sexual Health Research, University of Southampton, England, and her associates.

In contrast, only 2% of the teens were unaware that sexually transmitted diseases (STDs) can be transmitted through “vaginal intercourse with ejaculation” (Perspect. Sex. Reprod. Health. 2006;38:6–12).

The study included a survey of more than 1,300 British teenagers and analysis of sexual event diaries of more than 100 of the teenagers. Knowledge of STD transmission improved among older girls. Only 5% of 18-year-old girls did not know that STDs could be transmitted during oral sex, compared with about 22% of 16-year-old girls.

“It is essential that those charged with teaching youth about sexual issues—whether in schools, in clinics or in homes—be encouraged to broaden the scope of their coverage,” the researchers wrote.

More than one-quarter of teenagers in a recent survey did not know that sexually transmitted diseases can be passed through oral sex, reported Ms. Nicole Stone, at the Centre for Sexual Health Research, University of Southampton, England, and her associates.

In contrast, only 2% of the teens were unaware that sexually transmitted diseases (STDs) can be transmitted through “vaginal intercourse with ejaculation” (Perspect. Sex. Reprod. Health. 2006;38:6–12).

The study included a survey of more than 1,300 British teenagers and analysis of sexual event diaries of more than 100 of the teenagers. Knowledge of STD transmission improved among older girls. Only 5% of 18-year-old girls did not know that STDs could be transmitted during oral sex, compared with about 22% of 16-year-old girls.

“It is essential that those charged with teaching youth about sexual issues—whether in schools, in clinics or in homes—be encouraged to broaden the scope of their coverage,” the researchers wrote.

More than one-quarter of teenagers in a recent survey did not know that sexually transmitted diseases can be passed through oral sex, reported Ms. Nicole Stone, at the Centre for Sexual Health Research, University of Southampton, England, and her associates.

In contrast, only 2% of the teens were unaware that sexually transmitted diseases (STDs) can be transmitted through “vaginal intercourse with ejaculation” (Perspect. Sex. Reprod. Health. 2006;38:6–12).

The study included a survey of more than 1,300 British teenagers and analysis of sexual event diaries of more than 100 of the teenagers. Knowledge of STD transmission improved among older girls. Only 5% of 18-year-old girls did not know that STDs could be transmitted during oral sex, compared with about 22% of 16-year-old girls.

“It is essential that those charged with teaching youth about sexual issues—whether in schools, in clinics or in homes—be encouraged to broaden the scope of their coverage,” the researchers wrote.

PHILADELPHIA — Be careful how you code for consultations because Medicare contractors will be watching this area carefully, coding experts said at the annual meeting of the American College of Physicians.

In March, the Department of Health and Human Services Office of Inspector General (OIG) issued a report highlighting more than $1 billion in estimated overpayments made to physicians in 2001 for consultations under Medicare. In many cases, services were incorrectly billed as consultations, coded for the incorrect type or level of consultation, or were not supported by documentation, according to the OIG report.

OIG officials selected a random sample of 400 consultations allowed by Medicare during 2001, obtained photocopies of portions of patients' medical records, and hired certified professional coders to audit the claims. The results of that audit were extrapolated to produce the $1.1 billion overpayment estimate. Officials found the most problems with consultations billed at the highest billing level and with follow-up inpatient consultations, according to the OIG report.

Pay attention to the definition of and the elements involved in high-level consultation codes, advised Dr. Glenn D. Littenberg, chair of the ACP subcommittee on coding and reimbursement. He urged physicians to keep in mind that a level 5 consultation code involves an extended history of the present illness, a complete system review, a complete family social history, a comprehensive physical exam, and high-complexity decision making.

Complete documentation is essential and should include the request from the referral source, what services were provided by the physician, and the report back to the referral source, Dr. Littenberg said. “It's highly likely that based on [the OIG] report, carriers will be paying a little more attention to consultation coding at the high level,” he said.

Officials at the Centers for Medicare and Medicaid Services have already made some changes in consultation coding this year. Beginning this year, CMS has eliminated the CPT codes for follow-up inpatient consultations (99261–99263) and confirmatory consultations or second opinions (99271–99275).

In the office setting, physicians can use the office or other outpatient consultation codes (99241–99245) for initial consults and the office or other established patient codes (99212–99215) for follow-up visits.

Consultations that are requested by the family or patient instead of a physician cannot be billed using consultation codes, according to CMS, and instead physicians should rely on existing E/M codes for the setting where the service is provided.

The OIG report is available online at www.oig.hhs.gov/oei/reports/oei-09-02-00030.pdf

PHILADELPHIA — Be careful how you code for consultations because Medicare contractors will be watching this area carefully, coding experts said at the annual meeting of the American College of Physicians.

In March, the Department of Health and Human Services Office of Inspector General (OIG) issued a report highlighting more than $1 billion in estimated overpayments made to physicians in 2001 for consultations under Medicare. In many cases, services were incorrectly billed as consultations, coded for the incorrect type or level of consultation, or were not supported by documentation, according to the OIG report.

OIG officials selected a random sample of 400 consultations allowed by Medicare during 2001, obtained photocopies of portions of patients' medical records, and hired certified professional coders to audit the claims. The results of that audit were extrapolated to produce the $1.1 billion overpayment estimate. Officials found the most problems with consultations billed at the highest billing level and with follow-up inpatient consultations, according to the OIG report.

Pay attention to the definition of and the elements involved in high-level consultation codes, advised Dr. Glenn D. Littenberg, chair of the ACP subcommittee on coding and reimbursement. He urged physicians to keep in mind that a level 5 consultation code involves an extended history of the present illness, a complete system review, a complete family social history, a comprehensive physical exam, and high-complexity decision making.

Complete documentation is essential and should include the request from the referral source, what services were provided by the physician, and the report back to the referral source, Dr. Littenberg said. “It's highly likely that based on [the OIG] report, carriers will be paying a little more attention to consultation coding at the high level,” he said.

Officials at the Centers for Medicare and Medicaid Services have already made some changes in consultation coding this year. Beginning this year, CMS has eliminated the CPT codes for follow-up inpatient consultations (99261–99263) and confirmatory consultations or second opinions (99271–99275).

In the office setting, physicians can use the office or other outpatient consultation codes (99241–99245) for initial consults and the office or other established patient codes (99212–99215) for follow-up visits.

Consultations that are requested by the family or patient instead of a physician cannot be billed using consultation codes, according to CMS, and instead physicians should rely on existing E/M codes for the setting where the service is provided.

The OIG report is available online at www.oig.hhs.gov/oei/reports/oei-09-02-00030.pdf

PHILADELPHIA — Be careful how you code for consultations because Medicare contractors will be watching this area carefully, coding experts said at the annual meeting of the American College of Physicians.

In March, the Department of Health and Human Services Office of Inspector General (OIG) issued a report highlighting more than $1 billion in estimated overpayments made to physicians in 2001 for consultations under Medicare. In many cases, services were incorrectly billed as consultations, coded for the incorrect type or level of consultation, or were not supported by documentation, according to the OIG report.

OIG officials selected a random sample of 400 consultations allowed by Medicare during 2001, obtained photocopies of portions of patients' medical records, and hired certified professional coders to audit the claims. The results of that audit were extrapolated to produce the $1.1 billion overpayment estimate. Officials found the most problems with consultations billed at the highest billing level and with follow-up inpatient consultations, according to the OIG report.

Pay attention to the definition of and the elements involved in high-level consultation codes, advised Dr. Glenn D. Littenberg, chair of the ACP subcommittee on coding and reimbursement. He urged physicians to keep in mind that a level 5 consultation code involves an extended history of the present illness, a complete system review, a complete family social history, a comprehensive physical exam, and high-complexity decision making.

Complete documentation is essential and should include the request from the referral source, what services were provided by the physician, and the report back to the referral source, Dr. Littenberg said. “It's highly likely that based on [the OIG] report, carriers will be paying a little more attention to consultation coding at the high level,” he said.

Officials at the Centers for Medicare and Medicaid Services have already made some changes in consultation coding this year. Beginning this year, CMS has eliminated the CPT codes for follow-up inpatient consultations (99261–99263) and confirmatory consultations or second opinions (99271–99275).

In the office setting, physicians can use the office or other outpatient consultation codes (99241–99245) for initial consults and the office or other established patient codes (99212–99215) for follow-up visits.

Consultations that are requested by the family or patient instead of a physician cannot be billed using consultation codes, according to CMS, and instead physicians should rely on existing E/M codes for the setting where the service is provided.

The OIG report is available online at www.oig.hhs.gov/oei/reports/oei-09-02-00030.pdf

Successful implementation of an electronic medical record system to improve quality requires attention and effort from physicians at the beginning of the process, according to experts.

The more time physicians spend up front customizing the system to fit their needs, the less they will struggle later on, said Dr. Barry Bershow, director of quality and informatics at Fairview Health Services in Minnesota.

Dr. Bershow has seen first hand how effective electronic medical record tools can improve quality. At Fairview Health Services, which includes hospital and clinics across Minnesota, there has been significant improvement in quality measures in recent years. For example, screening for chlamydia has nearly doubled from 2004 to 2005, and there have been dramatic improvements in asthma management and obesity screening.

Electronic medical records can also improve quality within small practices, he said. Before coming to work for the Fairview system 2 years ago, Dr. Bershow spent about 28 years working in a small family medicine practice affiliated with the Fairview system. In 1999, the practice became a pilot site to test Fairview's electronic medical record. The implementation proved successful, and the practice continues to use the system today.

Implemention of the EMR system led to reduction of staff by approximately four full-time employees and to improvements in quality, particularly in coronary artery disease and diabetes care, Dr. Bershow said.

“It wasn't just because we were really good doctors,” he said. In fact, the performance improvements they saw were in areas where the EMR included clinical decision support and other prompts.

But Dr. Bershow doesn't downplay the tough transition to the system. He said it took 3 months before the physicians in the practice could start to go home at the same time they did before implementation. But at 6 months, half of the physicians were going home earlier than before, he said.

In the first couple of months, physician and staff satisfaction dropped, according to satisfaction surveys, he said. At that point the excitement was gone, and they had yet to realize the benefits, Dr. Bershow said. But at 4–6 months, patients started coming in for return visits, and staff began to see efficiency in the system. At 6 months, all the results had improved including patient satisfaction, he said.

One common mistake that physicians make is not building in the shortcuts at the beginning, Dr. Bershow said.

Implemention of an electronic health record is not a guarantee of improved quality. In fact, a qualitative look at one suburban family medicine practice shows that a lack of communication about the goals of the EMR has actually led to a drop in quality improvement activities.

Jesse C. Crosson, Ph.D., of the New Jersey Medical School, Newark, and his colleagues, analyzed the EMR use of a family medicine practice in an upper middle-class suburban community in 2002 with follow-up in 2003 (Ann. Fam. Med. 2005;3:307–11).

Dr. Crosson and his team found that before the implementation of the EMR, the practice had used reminder stickers on their paper charts for screening, prevention, and disease management. However, when the practice switched to an electronic system, the EMR's built-in reminders were disabled because they were too cumbersome, leaving the practice without any formal reminder system.

The lack of communication was a real obstacle in this practice, Dr. Crosson said in an interview. He recommended that physicians planning to implement an EMR sit down early on with a broad group of people within the practice to figure out how to maintain the existing quality of care system once the electronic system is in place. This could mean having duplicate systems in place during the transition period, he said.

One barrier to realizing the full potential of EMR systems is that physicians are trained to take care of one person at a time, Dr. Crosson said, and many of the innovative EMR functions help in caring for groups of patients. There needs to be a shift in the mind set of physicians in order to truly take advantage of the advances in technology, he said.

When shopping for an EMR that can aid in the collection and reporting of quality improvement measures, look for a system that can export the data in an electronic format, said Dr. David C. Kibbe, director of the American Academy of Family Physicians' Center for Health Information Technology.

Most EMRs today allow physicians to export clinical data electronically to a health plan or other third party. Some of the more expensive systems allow physicians to analyze their own data and produce reports on their performance.

AHRQ's Health IT Lessons Online

Officials at the Agency for Healthcare Research and Quality are putting out some of the lessons learned from their health information technology projects. The information is available on the ARHQ Web site—

www.healthit.ahrq.gov

The Web site includes some of the early lessons from AHRQ-funded projects in a range of settings including health plans, hospitals, and small practices. The site also features links to more than 5,000 health IT resources, an evaluation tool kit to help implement health IT projects, and funding information.

“Adoption of health IT will be too slow if providers have to reinvent the wheel one by one,” AHRQ Director Dr. Carolyn Clancy said in a statement. “This shared learning tool brings the lessons of experience together in one place, so we can help providers avoid problems and achieve greater benefits when they make their move to health IT.”

Successful implementation of an electronic medical record system to improve quality requires attention and effort from physicians at the beginning of the process, according to experts.

The more time physicians spend up front customizing the system to fit their needs, the less they will struggle later on, said Dr. Barry Bershow, director of quality and informatics at Fairview Health Services in Minnesota.

Dr. Bershow has seen first hand how effective electronic medical record tools can improve quality. At Fairview Health Services, which includes hospital and clinics across Minnesota, there has been significant improvement in quality measures in recent years. For example, screening for chlamydia has nearly doubled from 2004 to 2005, and there have been dramatic improvements in asthma management and obesity screening.

Electronic medical records can also improve quality within small practices, he said. Before coming to work for the Fairview system 2 years ago, Dr. Bershow spent about 28 years working in a small family medicine practice affiliated with the Fairview system. In 1999, the practice became a pilot site to test Fairview's electronic medical record. The implementation proved successful, and the practice continues to use the system today.

Implemention of the EMR system led to reduction of staff by approximately four full-time employees and to improvements in quality, particularly in coronary artery disease and diabetes care, Dr. Bershow said.

“It wasn't just because we were really good doctors,” he said. In fact, the performance improvements they saw were in areas where the EMR included clinical decision support and other prompts.

But Dr. Bershow doesn't downplay the tough transition to the system. He said it took 3 months before the physicians in the practice could start to go home at the same time they did before implementation. But at 6 months, half of the physicians were going home earlier than before, he said.

In the first couple of months, physician and staff satisfaction dropped, according to satisfaction surveys, he said. At that point the excitement was gone, and they had yet to realize the benefits, Dr. Bershow said. But at 4–6 months, patients started coming in for return visits, and staff began to see efficiency in the system. At 6 months, all the results had improved including patient satisfaction, he said.

One common mistake that physicians make is not building in the shortcuts at the beginning, Dr. Bershow said.

Implemention of an electronic health record is not a guarantee of improved quality. In fact, a qualitative look at one suburban family medicine practice shows that a lack of communication about the goals of the EMR has actually led to a drop in quality improvement activities.

Jesse C. Crosson, Ph.D., of the New Jersey Medical School, Newark, and his colleagues, analyzed the EMR use of a family medicine practice in an upper middle-class suburban community in 2002 with follow-up in 2003 (Ann. Fam. Med. 2005;3:307–11).

Dr. Crosson and his team found that before the implementation of the EMR, the practice had used reminder stickers on their paper charts for screening, prevention, and disease management. However, when the practice switched to an electronic system, the EMR's built-in reminders were disabled because they were too cumbersome, leaving the practice without any formal reminder system.

The lack of communication was a real obstacle in this practice, Dr. Crosson said in an interview. He recommended that physicians planning to implement an EMR sit down early on with a broad group of people within the practice to figure out how to maintain the existing quality of care system once the electronic system is in place. This could mean having duplicate systems in place during the transition period, he said.

One barrier to realizing the full potential of EMR systems is that physicians are trained to take care of one person at a time, Dr. Crosson said, and many of the innovative EMR functions help in caring for groups of patients. There needs to be a shift in the mind set of physicians in order to truly take advantage of the advances in technology, he said.

When shopping for an EMR that can aid in the collection and reporting of quality improvement measures, look for a system that can export the data in an electronic format, said Dr. David C. Kibbe, director of the American Academy of Family Physicians' Center for Health Information Technology.

Most EMRs today allow physicians to export clinical data electronically to a health plan or other third party. Some of the more expensive systems allow physicians to analyze their own data and produce reports on their performance.

AHRQ's Health IT Lessons Online

Officials at the Agency for Healthcare Research and Quality are putting out some of the lessons learned from their health information technology projects. The information is available on the ARHQ Web site—

www.healthit.ahrq.gov

The Web site includes some of the early lessons from AHRQ-funded projects in a range of settings including health plans, hospitals, and small practices. The site also features links to more than 5,000 health IT resources, an evaluation tool kit to help implement health IT projects, and funding information.

“Adoption of health IT will be too slow if providers have to reinvent the wheel one by one,” AHRQ Director Dr. Carolyn Clancy said in a statement. “This shared learning tool brings the lessons of experience together in one place, so we can help providers avoid problems and achieve greater benefits when they make their move to health IT.”

Successful implementation of an electronic medical record system to improve quality requires attention and effort from physicians at the beginning of the process, according to experts.

The more time physicians spend up front customizing the system to fit their needs, the less they will struggle later on, said Dr. Barry Bershow, director of quality and informatics at Fairview Health Services in Minnesota.

Dr. Bershow has seen first hand how effective electronic medical record tools can improve quality. At Fairview Health Services, which includes hospital and clinics across Minnesota, there has been significant improvement in quality measures in recent years. For example, screening for chlamydia has nearly doubled from 2004 to 2005, and there have been dramatic improvements in asthma management and obesity screening.

Electronic medical records can also improve quality within small practices, he said. Before coming to work for the Fairview system 2 years ago, Dr. Bershow spent about 28 years working in a small family medicine practice affiliated with the Fairview system. In 1999, the practice became a pilot site to test Fairview's electronic medical record. The implementation proved successful, and the practice continues to use the system today.

Implemention of the EMR system led to reduction of staff by approximately four full-time employees and to improvements in quality, particularly in coronary artery disease and diabetes care, Dr. Bershow said.

“It wasn't just because we were really good doctors,” he said. In fact, the performance improvements they saw were in areas where the EMR included clinical decision support and other prompts.

But Dr. Bershow doesn't downplay the tough transition to the system. He said it took 3 months before the physicians in the practice could start to go home at the same time they did before implementation. But at 6 months, half of the physicians were going home earlier than before, he said.

In the first couple of months, physician and staff satisfaction dropped, according to satisfaction surveys, he said. At that point the excitement was gone, and they had yet to realize the benefits, Dr. Bershow said. But at 4–6 months, patients started coming in for return visits, and staff began to see efficiency in the system. At 6 months, all the results had improved including patient satisfaction, he said.

One common mistake that physicians make is not building in the shortcuts at the beginning, Dr. Bershow said.

Implemention of an electronic health record is not a guarantee of improved quality. In fact, a qualitative look at one suburban family medicine practice shows that a lack of communication about the goals of the EMR has actually led to a drop in quality improvement activities.

Jesse C. Crosson, Ph.D., of the New Jersey Medical School, Newark, and his colleagues, analyzed the EMR use of a family medicine practice in an upper middle-class suburban community in 2002 with follow-up in 2003 (Ann. Fam. Med. 2005;3:307–11).

Dr. Crosson and his team found that before the implementation of the EMR, the practice had used reminder stickers on their paper charts for screening, prevention, and disease management. However, when the practice switched to an electronic system, the EMR's built-in reminders were disabled because they were too cumbersome, leaving the practice without any formal reminder system.

The lack of communication was a real obstacle in this practice, Dr. Crosson said in an interview. He recommended that physicians planning to implement an EMR sit down early on with a broad group of people within the practice to figure out how to maintain the existing quality of care system once the electronic system is in place. This could mean having duplicate systems in place during the transition period, he said.

One barrier to realizing the full potential of EMR systems is that physicians are trained to take care of one person at a time, Dr. Crosson said, and many of the innovative EMR functions help in caring for groups of patients. There needs to be a shift in the mind set of physicians in order to truly take advantage of the advances in technology, he said.

When shopping for an EMR that can aid in the collection and reporting of quality improvement measures, look for a system that can export the data in an electronic format, said Dr. David C. Kibbe, director of the American Academy of Family Physicians' Center for Health Information Technology.

Most EMRs today allow physicians to export clinical data electronically to a health plan or other third party. Some of the more expensive systems allow physicians to analyze their own data and produce reports on their performance.

AHRQ's Health IT Lessons Online

Officials at the Agency for Healthcare Research and Quality are putting out some of the lessons learned from their health information technology projects. The information is available on the ARHQ Web site—

www.healthit.ahrq.gov

The Web site includes some of the early lessons from AHRQ-funded projects in a range of settings including health plans, hospitals, and small practices. The site also features links to more than 5,000 health IT resources, an evaluation tool kit to help implement health IT projects, and funding information.

“Adoption of health IT will be too slow if providers have to reinvent the wheel one by one,” AHRQ Director Dr. Carolyn Clancy said in a statement. “This shared learning tool brings the lessons of experience together in one place, so we can help providers avoid problems and achieve greater benefits when they make their move to health IT.”

More than 2 years after President Bush issued his call to action on the adoption of electronic health records, experts say there is growing pressure on physicians to heed that call.

While physician adoption of EHRs remains low—especially in small practices—the movement toward pay for performance could start to drive adoption, said Mureen Allen, senior associate for informatics and practice improvement at the American College of Physicians. And the certification of electronic health records by an independent body, which is slated to begin this summer, should help too. “The paradigm to some extent is changing.”

This month, many of the biggest players in health information technology will gather in Washington for National Health IT Week. More than 40 groups are slated to participate in this first-ever event, including medical professional societies such the American Academy of Family Physicians, government agencies, a regional health information organization, and other public and private organizations.

The series of events follows on the heels of more than 2 years' major actions in the health IT landscape starting with President Bush's State of the Union address in January 2004 in which he called for the widespread adoption of interoperable EHRs within the decade.

A few months later, the Health and Human Services secretary appointed Dr. David J. Brailer as the first National Health Information Technology Coordinator. Dr. Brailer resigned from the post last month saying that he only planned to stay in the job for 2 years. Dr. Brailer said there is still a lot work to be done in closing the adoption gap between large and small physician practices. His office has been focused on three strategies to close the gap—lowering costs, raising the benefits, and lowering the risks involved in purchasing an EHR system, he said during a teleconference announcing his resignation.

Last fall, HHS Secretary Mike Leavitt established the American Health Information Community, a federally chartered commission to advise the secretary on interoperability issues. HHS proposed allowing hospitals and other entities to give physicians health IT hardware, software, and training.

HHS also awarded three contracts to public and private groups to create processes for harmonizing information standards, certifying health IT products, and addressing variations in state laws on privacy and security practices.

And starting in January, prescription drug plans participating in the Medicare Part D program were required to begin supporting electronic prescribing. The regulation is optional for physicians and pharmacies.

Most recently, the Food and Drug Administration adopted the Systematized Nomenclature of Medicine (SNOMED) standard as the format for the highlights section of prescription drug labeling. The format will be required starting on June 30 for all new drugs and drugs approved within the last 5 years. The use of the SNOMED standards will make it easier for electronic systems to exchange FDA-approved labeling information, according to the agency.

One of the most significant developments has been the establishment of the Certification Commission on Health Information Technology (CCHIT). This group was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society (HIMSS), and the National Alliance for Health Information Technology to develop criteria for the certification of EHRs.

CCHIT received a 3-year grant from HHS last fall to certify products in the ambulatory and inpatient settings, and to certify the systems' networks. The announcement of the first certified products in the ambulatory setting is expected in late June or early July.

The means for objectively comparing EHR systems is “about to become a reality,” said CCHIT Chair Dr. Mark Leavitt. Current estimates put physician adoption of EHRs at around 14%. Dr. Leavitt said he hopes that by taking some of the risk out of buying an EHR product it will boost those adoption figures.

“I think we are on track,” said Dave Roberts, vice president of government relations at HIMSS. While physicians still need to be educated about the value of EHRs, there are some other encouraging signs. For example, many states are becoming more interested in health IT and are helping to form regional health information organizations, he said.

These groups, called RHIOs, help to standardize the various regulations and business policies surrounding health information exchange. The federal government has funded more than 100 of these regional projects, and more efforts, supported by private industry or state governments, are underway, according to HHS.

“The states are really buying into this whole initiative,” Mr. Roberts said.

For the majority of physicians, it just has not made financial sense to purchase an EHR system, Dr. Allen said. However, some physicians are beginning to see a strategic advantage in the adoption of technology. One advantage stems from regulations that encourage electronic prescribing.

EHR adoption is inevitable, Dr. Allen said, if only because so many new physicians are being trained on EHRs, and it is not acceptable to them to go back to a paper system once they enter practice. And older physicians recognize that the change is coming, she said.

More than 2 years after President Bush issued his call to action on the adoption of electronic health records, experts say there is growing pressure on physicians to heed that call.

While physician adoption of EHRs remains low—especially in small practices—the movement toward pay for performance could start to drive adoption, said Mureen Allen, senior associate for informatics and practice improvement at the American College of Physicians. And the certification of electronic health records by an independent body, which is slated to begin this summer, should help too. “The paradigm to some extent is changing.”

This month, many of the biggest players in health information technology will gather in Washington for National Health IT Week. More than 40 groups are slated to participate in this first-ever event, including medical professional societies such the American Academy of Family Physicians, government agencies, a regional health information organization, and other public and private organizations.

The series of events follows on the heels of more than 2 years' major actions in the health IT landscape starting with President Bush's State of the Union address in January 2004 in which he called for the widespread adoption of interoperable EHRs within the decade.

A few months later, the Health and Human Services secretary appointed Dr. David J. Brailer as the first National Health Information Technology Coordinator. Dr. Brailer resigned from the post last month saying that he only planned to stay in the job for 2 years. Dr. Brailer said there is still a lot work to be done in closing the adoption gap between large and small physician practices. His office has been focused on three strategies to close the gap—lowering costs, raising the benefits, and lowering the risks involved in purchasing an EHR system, he said during a teleconference announcing his resignation.

Last fall, HHS Secretary Mike Leavitt established the American Health Information Community, a federally chartered commission to advise the secretary on interoperability issues. HHS proposed allowing hospitals and other entities to give physicians health IT hardware, software, and training.

HHS also awarded three contracts to public and private groups to create processes for harmonizing information standards, certifying health IT products, and addressing variations in state laws on privacy and security practices.

And starting in January, prescription drug plans participating in the Medicare Part D program were required to begin supporting electronic prescribing. The regulation is optional for physicians and pharmacies.

Most recently, the Food and Drug Administration adopted the Systematized Nomenclature of Medicine (SNOMED) standard as the format for the highlights section of prescription drug labeling. The format will be required starting on June 30 for all new drugs and drugs approved within the last 5 years. The use of the SNOMED standards will make it easier for electronic systems to exchange FDA-approved labeling information, according to the agency.

One of the most significant developments has been the establishment of the Certification Commission on Health Information Technology (CCHIT). This group was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society (HIMSS), and the National Alliance for Health Information Technology to develop criteria for the certification of EHRs.

CCHIT received a 3-year grant from HHS last fall to certify products in the ambulatory and inpatient settings, and to certify the systems' networks. The announcement of the first certified products in the ambulatory setting is expected in late June or early July.

The means for objectively comparing EHR systems is “about to become a reality,” said CCHIT Chair Dr. Mark Leavitt. Current estimates put physician adoption of EHRs at around 14%. Dr. Leavitt said he hopes that by taking some of the risk out of buying an EHR product it will boost those adoption figures.

“I think we are on track,” said Dave Roberts, vice president of government relations at HIMSS. While physicians still need to be educated about the value of EHRs, there are some other encouraging signs. For example, many states are becoming more interested in health IT and are helping to form regional health information organizations, he said.

These groups, called RHIOs, help to standardize the various regulations and business policies surrounding health information exchange. The federal government has funded more than 100 of these regional projects, and more efforts, supported by private industry or state governments, are underway, according to HHS.

“The states are really buying into this whole initiative,” Mr. Roberts said.

For the majority of physicians, it just has not made financial sense to purchase an EHR system, Dr. Allen said. However, some physicians are beginning to see a strategic advantage in the adoption of technology. One advantage stems from regulations that encourage electronic prescribing.

EHR adoption is inevitable, Dr. Allen said, if only because so many new physicians are being trained on EHRs, and it is not acceptable to them to go back to a paper system once they enter practice. And older physicians recognize that the change is coming, she said.

More than 2 years after President Bush issued his call to action on the adoption of electronic health records, experts say there is growing pressure on physicians to heed that call.

While physician adoption of EHRs remains low—especially in small practices—the movement toward pay for performance could start to drive adoption, said Mureen Allen, senior associate for informatics and practice improvement at the American College of Physicians. And the certification of electronic health records by an independent body, which is slated to begin this summer, should help too. “The paradigm to some extent is changing.”

This month, many of the biggest players in health information technology will gather in Washington for National Health IT Week. More than 40 groups are slated to participate in this first-ever event, including medical professional societies such the American Academy of Family Physicians, government agencies, a regional health information organization, and other public and private organizations.

The series of events follows on the heels of more than 2 years' major actions in the health IT landscape starting with President Bush's State of the Union address in January 2004 in which he called for the widespread adoption of interoperable EHRs within the decade.

A few months later, the Health and Human Services secretary appointed Dr. David J. Brailer as the first National Health Information Technology Coordinator. Dr. Brailer resigned from the post last month saying that he only planned to stay in the job for 2 years. Dr. Brailer said there is still a lot work to be done in closing the adoption gap between large and small physician practices. His office has been focused on three strategies to close the gap—lowering costs, raising the benefits, and lowering the risks involved in purchasing an EHR system, he said during a teleconference announcing his resignation.

Last fall, HHS Secretary Mike Leavitt established the American Health Information Community, a federally chartered commission to advise the secretary on interoperability issues. HHS proposed allowing hospitals and other entities to give physicians health IT hardware, software, and training.

HHS also awarded three contracts to public and private groups to create processes for harmonizing information standards, certifying health IT products, and addressing variations in state laws on privacy and security practices.

And starting in January, prescription drug plans participating in the Medicare Part D program were required to begin supporting electronic prescribing. The regulation is optional for physicians and pharmacies.

Most recently, the Food and Drug Administration adopted the Systematized Nomenclature of Medicine (SNOMED) standard as the format for the highlights section of prescription drug labeling. The format will be required starting on June 30 for all new drugs and drugs approved within the last 5 years. The use of the SNOMED standards will make it easier for electronic systems to exchange FDA-approved labeling information, according to the agency.

One of the most significant developments has been the establishment of the Certification Commission on Health Information Technology (CCHIT). This group was formed in 2004 by the American Health Information Management Association, the Healthcare Information and Management Systems Society (HIMSS), and the National Alliance for Health Information Technology to develop criteria for the certification of EHRs.

CCHIT received a 3-year grant from HHS last fall to certify products in the ambulatory and inpatient settings, and to certify the systems' networks. The announcement of the first certified products in the ambulatory setting is expected in late June or early July.

The means for objectively comparing EHR systems is “about to become a reality,” said CCHIT Chair Dr. Mark Leavitt. Current estimates put physician adoption of EHRs at around 14%. Dr. Leavitt said he hopes that by taking some of the risk out of buying an EHR product it will boost those adoption figures.

“I think we are on track,” said Dave Roberts, vice president of government relations at HIMSS. While physicians still need to be educated about the value of EHRs, there are some other encouraging signs. For example, many states are becoming more interested in health IT and are helping to form regional health information organizations, he said.

These groups, called RHIOs, help to standardize the various regulations and business policies surrounding health information exchange. The federal government has funded more than 100 of these regional projects, and more efforts, supported by private industry or state governments, are underway, according to HHS.

“The states are really buying into this whole initiative,” Mr. Roberts said.

For the majority of physicians, it just has not made financial sense to purchase an EHR system, Dr. Allen said. However, some physicians are beginning to see a strategic advantage in the adoption of technology. One advantage stems from regulations that encourage electronic prescribing.

EHR adoption is inevitable, Dr. Allen said, if only because so many new physicians are being trained on EHRs, and it is not acceptable to them to go back to a paper system once they enter practice. And older physicians recognize that the change is coming, she said.

PHILADELPHIA — A costly electronic health record system is not necessary to engage in quality improvement and participate in the growing number of pay-for-performance programs, Dr. Rodney Hornbake said at the annual meeting of the American College of Physicians.

Patient registry software is a lower-cost alternative that allows physicians to track their care of patients with chronic diseases.

“It's really an excellent starting place for quality improvement in the ambulatory setting,” said Dr. Hornbake, an internist in private practice in Essex, Conn.

Patient registries are one of the best tools for physicians participating in pay-for-performance programs, Dr. Hornbake said. Many electronic health records (EHRs) may not have population-based functionality, and therefore cannot generate simple reports on the physician's performance on certain measures. Most EHR vendors can build interfaces with patient registry software, but that's generally an added cost, he said.

There are a number of patient registry programs available; a comprehensive program can be purchased for less than $1,000 per provider, Dr. Hornbake said. Some are available for free.

For example, Dr. Hornbake tested the Comorbid Disease Management Database (COMMAND) software in his practice. This registry system is available for free from the Mississippi Quality Improvement Organization. And technology-savvy physicians can use programs like Microsoft Access to design their own registries, he said.

Dr. Hornbake tried out COMMAND in his practice to help keep up with the pay-for-performance programs in his local market. One insurer—Anthem Health Plans Inc. of Connecticut—has a program that offers incentives for process and outcomes measures, as well as for the use of health-related information technology, including electronic prescribing, EHRs, and patient registries. The insurer also offers incentives to physicians for generic prescribing, he said.

Dr. Hornbake said that he exported demographic information from his billing system into COMMAND and manually entered the clinical information from patient charts himself. After using the billing system to identify all of the patients who had conditions included in his registry, he had his staff put red stickers on those patient charts.

This flagged the patients for special attention from the staff, he said. For example, patients whose charts had stickers received follow-up calls if they missed an appointment. To keep the registry up to date, every 2 months the staff pulls the charts of all registry patients and Dr. Hornbake updates the system manually. He spends about 1.5 hours entering data on 125 patients, he said.

Dr. Hornbake said he prefers to enter the information in periodic batches because it helps him identify any chronic disease patients who have slipped through the cracks.

Even factoring in his time, Dr. Hornbake said that he saw an immediate return on investment with the patient registry system. Unlike implementation of an EHR system, he added, patient registry software tends to fit in easily with the normal workflow of the office.

Physicians can also manage their patient care using a paper-based patient registry, he said, but once they begin to track 20 or more measures, a paper system quickly becomes unworkable.

So far, Dr. Hornbake said he has resisted purchasing an EHR system because he still can't make a financial case for the investment. He advised physicians to buy or upgrade an EHR system based on its ability to support pay for performance and manage a population of specific patients. Many of the other selling points for an EHR system—that it will eliminate transcription, cut down on needed staff positions, and improve coding—don't hold true for all physicians, he said.

This Month's Talk Back Question

If you have used patient registry software in your practice, how useful has it been in caring for patients with chronic diseases?

PHILADELPHIA — A costly electronic health record system is not necessary to engage in quality improvement and participate in the growing number of pay-for-performance programs, Dr. Rodney Hornbake said at the annual meeting of the American College of Physicians.

Patient registry software is a lower-cost alternative that allows physicians to track their care of patients with chronic diseases.

“It's really an excellent starting place for quality improvement in the ambulatory setting,” said Dr. Hornbake, an internist in private practice in Essex, Conn.

Patient registries are one of the best tools for physicians participating in pay-for-performance programs, Dr. Hornbake said. Many electronic health records (EHRs) may not have population-based functionality, and therefore cannot generate simple reports on the physician's performance on certain measures. Most EHR vendors can build interfaces with patient registry software, but that's generally an added cost, he said.

There are a number of patient registry programs available; a comprehensive program can be purchased for less than $1,000 per provider, Dr. Hornbake said. Some are available for free.

For example, Dr. Hornbake tested the Comorbid Disease Management Database (COMMAND) software in his practice. This registry system is available for free from the Mississippi Quality Improvement Organization. And technology-savvy physicians can use programs like Microsoft Access to design their own registries, he said.

Dr. Hornbake tried out COMMAND in his practice to help keep up with the pay-for-performance programs in his local market. One insurer—Anthem Health Plans Inc. of Connecticut—has a program that offers incentives for process and outcomes measures, as well as for the use of health-related information technology, including electronic prescribing, EHRs, and patient registries. The insurer also offers incentives to physicians for generic prescribing, he said.

Dr. Hornbake said that he exported demographic information from his billing system into COMMAND and manually entered the clinical information from patient charts himself. After using the billing system to identify all of the patients who had conditions included in his registry, he had his staff put red stickers on those patient charts.

This flagged the patients for special attention from the staff, he said. For example, patients whose charts had stickers received follow-up calls if they missed an appointment. To keep the registry up to date, every 2 months the staff pulls the charts of all registry patients and Dr. Hornbake updates the system manually. He spends about 1.5 hours entering data on 125 patients, he said.

Dr. Hornbake said he prefers to enter the information in periodic batches because it helps him identify any chronic disease patients who have slipped through the cracks.

Even factoring in his time, Dr. Hornbake said that he saw an immediate return on investment with the patient registry system. Unlike implementation of an EHR system, he added, patient registry software tends to fit in easily with the normal workflow of the office.

Physicians can also manage their patient care using a paper-based patient registry, he said, but once they begin to track 20 or more measures, a paper system quickly becomes unworkable.

So far, Dr. Hornbake said he has resisted purchasing an EHR system because he still can't make a financial case for the investment. He advised physicians to buy or upgrade an EHR system based on its ability to support pay for performance and manage a population of specific patients. Many of the other selling points for an EHR system—that it will eliminate transcription, cut down on needed staff positions, and improve coding—don't hold true for all physicians, he said.

This Month's Talk Back Question

If you have used patient registry software in your practice, how useful has it been in caring for patients with chronic diseases?

PHILADELPHIA — A costly electronic health record system is not necessary to engage in quality improvement and participate in the growing number of pay-for-performance programs, Dr. Rodney Hornbake said at the annual meeting of the American College of Physicians.

Patient registry software is a lower-cost alternative that allows physicians to track their care of patients with chronic diseases.

“It's really an excellent starting place for quality improvement in the ambulatory setting,” said Dr. Hornbake, an internist in private practice in Essex, Conn.

Patient registries are one of the best tools for physicians participating in pay-for-performance programs, Dr. Hornbake said. Many electronic health records (EHRs) may not have population-based functionality, and therefore cannot generate simple reports on the physician's performance on certain measures. Most EHR vendors can build interfaces with patient registry software, but that's generally an added cost, he said.

There are a number of patient registry programs available; a comprehensive program can be purchased for less than $1,000 per provider, Dr. Hornbake said. Some are available for free.

For example, Dr. Hornbake tested the Comorbid Disease Management Database (COMMAND) software in his practice. This registry system is available for free from the Mississippi Quality Improvement Organization. And technology-savvy physicians can use programs like Microsoft Access to design their own registries, he said.

Dr. Hornbake tried out COMMAND in his practice to help keep up with the pay-for-performance programs in his local market. One insurer—Anthem Health Plans Inc. of Connecticut—has a program that offers incentives for process and outcomes measures, as well as for the use of health-related information technology, including electronic prescribing, EHRs, and patient registries. The insurer also offers incentives to physicians for generic prescribing, he said.

Dr. Hornbake said that he exported demographic information from his billing system into COMMAND and manually entered the clinical information from patient charts himself. After using the billing system to identify all of the patients who had conditions included in his registry, he had his staff put red stickers on those patient charts.

This flagged the patients for special attention from the staff, he said. For example, patients whose charts had stickers received follow-up calls if they missed an appointment. To keep the registry up to date, every 2 months the staff pulls the charts of all registry patients and Dr. Hornbake updates the system manually. He spends about 1.5 hours entering data on 125 patients, he said.

Dr. Hornbake said he prefers to enter the information in periodic batches because it helps him identify any chronic disease patients who have slipped through the cracks.

Even factoring in his time, Dr. Hornbake said that he saw an immediate return on investment with the patient registry system. Unlike implementation of an EHR system, he added, patient registry software tends to fit in easily with the normal workflow of the office.

Physicians can also manage their patient care using a paper-based patient registry, he said, but once they begin to track 20 or more measures, a paper system quickly becomes unworkable.

So far, Dr. Hornbake said he has resisted purchasing an EHR system because he still can't make a financial case for the investment. He advised physicians to buy or upgrade an EHR system based on its ability to support pay for performance and manage a population of specific patients. Many of the other selling points for an EHR system—that it will eliminate transcription, cut down on needed staff positions, and improve coding—don't hold true for all physicians, he said.

This Month's Talk Back Question

If you have used patient registry software in your practice, how useful has it been in caring for patients with chronic diseases?

PHILADELPHIA — Performance measurement is one way to help eliminate racial disparities in health care, Dr. John Z. Ayanian said at the annual meeting of the American College of Physicians.

Public and private payers must also do their part by maintaining accurate and complete data on race and ethnicity to help monitor disparities, said Dr. Ayanian, associate professor of medicine and health care policy at Harvard Medical School in Boston.

There has been some success in narrowing the racial care gap in areas where measurement is widespread. For example, a study published last year found both overall quality improvement in the use of β-blockers after acute myocardial infarction among Medicare managed-care beneficiaries and a significant narrowing of the racial gap in treatment. The treatment gap between African American and white beneficiaries had been 12% in 1997 and fell to 0.4% in 2002 (N. Engl. J. Med. 2005;353:692–700).

But there is still work to do, he said. For example, the same study shows that while overall quality improved in cholesterol control for coronary artery disease, the racial disparity is actually increasing in that measure. The study showed that the gap for cholesterol control, defined as LDL cholesterol below 130 mg/dL after discharge, between black and white patients was 13% in 1999, and the gap widened to 16% in 2002.

Lack of communication and trust between minority patients and physicians also are factors in care disparities, Dr. Ayanian said. Many physicians don't recognize the legacy of discrimination in health care, such as the Tuskegee syphilis study, that still fuels mistrust of the health care system among minorities, he said.

A cooperative national study conducted by Dr. Ayanian and his colleagues looked at new patient preferences for renal transplantation among end-stage renal disease patients ages 18 to 54 in Michigan, Alabama, Southern California, and the Washington metropolitan area in 1996–1997.

The researchers found small differences in the patient preferences for the transplant but larger differences in the referral for evaluation. For example, 86% of white men favored transplantation, and 82% were referred for evaluation. However, 81% of black men favored transplantation but only 58% were referred for evaluation (N. Engl. J. Med. 1999;341:1661–9).

In addition, most patients in the study said they agreed with and trusted their physician. But white patients were more likely to trust and agree with physicians than African American patients, and black patients received less information about transplantation.

PHILADELPHIA — Performance measurement is one way to help eliminate racial disparities in health care, Dr. John Z. Ayanian said at the annual meeting of the American College of Physicians.

Public and private payers must also do their part by maintaining accurate and complete data on race and ethnicity to help monitor disparities, said Dr. Ayanian, associate professor of medicine and health care policy at Harvard Medical School in Boston.

There has been some success in narrowing the racial care gap in areas where measurement is widespread. For example, a study published last year found both overall quality improvement in the use of β-blockers after acute myocardial infarction among Medicare managed-care beneficiaries and a significant narrowing of the racial gap in treatment. The treatment gap between African American and white beneficiaries had been 12% in 1997 and fell to 0.4% in 2002 (N. Engl. J. Med. 2005;353:692–700).

But there is still work to do, he said. For example, the same study shows that while overall quality improved in cholesterol control for coronary artery disease, the racial disparity is actually increasing in that measure. The study showed that the gap for cholesterol control, defined as LDL cholesterol below 130 mg/dL after discharge, between black and white patients was 13% in 1999, and the gap widened to 16% in 2002.

Lack of communication and trust between minority patients and physicians also are factors in care disparities, Dr. Ayanian said. Many physicians don't recognize the legacy of discrimination in health care, such as the Tuskegee syphilis study, that still fuels mistrust of the health care system among minorities, he said.

A cooperative national study conducted by Dr. Ayanian and his colleagues looked at new patient preferences for renal transplantation among end-stage renal disease patients ages 18 to 54 in Michigan, Alabama, Southern California, and the Washington metropolitan area in 1996–1997.

The researchers found small differences in the patient preferences for the transplant but larger differences in the referral for evaluation. For example, 86% of white men favored transplantation, and 82% were referred for evaluation. However, 81% of black men favored transplantation but only 58% were referred for evaluation (N. Engl. J. Med. 1999;341:1661–9).

In addition, most patients in the study said they agreed with and trusted their physician. But white patients were more likely to trust and agree with physicians than African American patients, and black patients received less information about transplantation.

PHILADELPHIA — Performance measurement is one way to help eliminate racial disparities in health care, Dr. John Z. Ayanian said at the annual meeting of the American College of Physicians.

Public and private payers must also do their part by maintaining accurate and complete data on race and ethnicity to help monitor disparities, said Dr. Ayanian, associate professor of medicine and health care policy at Harvard Medical School in Boston.

There has been some success in narrowing the racial care gap in areas where measurement is widespread. For example, a study published last year found both overall quality improvement in the use of β-blockers after acute myocardial infarction among Medicare managed-care beneficiaries and a significant narrowing of the racial gap in treatment. The treatment gap between African American and white beneficiaries had been 12% in 1997 and fell to 0.4% in 2002 (N. Engl. J. Med. 2005;353:692–700).

But there is still work to do, he said. For example, the same study shows that while overall quality improved in cholesterol control for coronary artery disease, the racial disparity is actually increasing in that measure. The study showed that the gap for cholesterol control, defined as LDL cholesterol below 130 mg/dL after discharge, between black and white patients was 13% in 1999, and the gap widened to 16% in 2002.

Lack of communication and trust between minority patients and physicians also are factors in care disparities, Dr. Ayanian said. Many physicians don't recognize the legacy of discrimination in health care, such as the Tuskegee syphilis study, that still fuels mistrust of the health care system among minorities, he said.

A cooperative national study conducted by Dr. Ayanian and his colleagues looked at new patient preferences for renal transplantation among end-stage renal disease patients ages 18 to 54 in Michigan, Alabama, Southern California, and the Washington metropolitan area in 1996–1997.

The researchers found small differences in the patient preferences for the transplant but larger differences in the referral for evaluation. For example, 86% of white men favored transplantation, and 82% were referred for evaluation. However, 81% of black men favored transplantation but only 58% were referred for evaluation (N. Engl. J. Med. 1999;341:1661–9).

In addition, most patients in the study said they agreed with and trusted their physician. But white patients were more likely to trust and agree with physicians than African American patients, and black patients received less information about transplantation.

PHILADELPHIA — The effect that any future Medicare-run pay-for-performance program would have on primary care physicians is still very much up in the air, experts said at the annual meeting of the American College of Physicians.

Medicare currently has no pay-for-performance programs in effect, and—although the agency has various demonstrations and pilots underway to look at this issue—the real effect of such a program is still a matter of speculation, said Dr. John Tooker, ACP's executive vice president and chief executive officer.

But Dr. Tooker urged physicians to consider participating in what may be a precursor to a Medicare pay-for performance program: the Physician Voluntary Reporting Program. The initiative, launched earlier this year by officials at the Centers for Medicare and Medicaid Services, asks physicians to report on a core starter set of 16 quality measures. There is no funding attached to the program at this point.

“It's a good way to begin to learn how to do this in your practice,” Dr. Tooker said. “But most importantly, I think it's really a matter of learning to change the culture of a practice.”

If done right, pay-for-performance programs could result in higher quality patient care and increased physician and patient satisfaction, said Dr. C. Anderson Hedberg, ACP's immediate past president.

But the ACP is concerned that such programs could also lead to increased paperwork burdens, higher expenses, less revenue, and time taken away from patient care, he said. And there could be unintended consequences for sicker and noncompliant patients. Much will depend on what measures are used, how quickly they are phased in, how data will be collected, the type of public reporting involved, and the incentives applied, he said.

ACP officials aren't the only physicians who have questions about how pay-for-performance programs—whether through Medicare or private insurers—will affect their practices. At the ACP's town hall meeting on the issue, Dr. Emily R. Transue, an internist in a group practice in Seattle, said there is still not a set of consistent and appropriate quality measures that everyone has agreed to use. For example, she received two reports on her performance from two different companies. In one report she was rated as a high performer, and in the other her quality of care was considered below average. “Clearly there's something that isn't fitting together,” she said.

If physicians can't come up with appropriate quality measures, these programs will end up just being another set of hoops that physicians have to jump through, she said.

Dr. Teresa M. Schaer, a geriatrician at St. Peter's University Hospital in New Brunswick, N.J., said she would like to see measures that are on topics of importance to Medicare beneficiaries, such as counseling about end-of-life planning. When she spends 40 minutes discussing such preferences with a patient who has Parkinson's disease, she would like to see such counseling recognized as high-quality care.

Dr. Barry M. Straube, acting director of the Office of Clinical Standards and Quality at CMS, acknowledged that some of the measures the agency has been focused on may not be relevant to older Medicare patients. Officials at CMS have been discussing how to assess quality care in special populations, he said.

But the ongoing quality work is being done in collaboration with Medicaid and commercial health plans, so for now the focus is on measures that apply to a broad population, Dr. Straube said.

One program that has been a pioneer in this area was formulated by the Bridges to Excellence coalition, which was founded by a number of larger employers and offers incentives to physicians who demonstrate quality care. To date, the program has shown that in communities where incentives are available, there has not been patient dumping, said Francois deBrantes, national coordinator of the program. “That's not how good performance is achieved.” In fact, after physicians devoted time to reengineering their practices, they generally sought out more patients, he said.

Officials with the program have also found that the financial incentives are effective, and that the size of the incentive has a direct relationship to whether physicians are willing to go through an expensive and time-consuming overhaul of their practices. Asking a physician to make these changes for $1,000 a year is an insult, Mr. deBrantes said.

Incentivizing physicians to provide higher quality care has also paid off for payers, he said. They have found that patients who are managed for their chronic conditions have more office visits and fewer hospital stays, which produces an average 10% savings for payers.

But setting up incentive programs is not a small task, Mr. deBrantes said. Because incentives need to be large enough to encourage physicians to make significant practice changes, it's hard for any one employer or health plan to set up rewards programs.

It's also a major undertaking for physicians and their staffs, especially given the cost and complexity of electronic health record systems. (See box.) The transition from a paper-based practice to something more systematic takes about a year and a half with outside help, which, for small practices, is nearly impossible to make the transition without, Mr. deBrantes said.

Some of the measures may not be relevant to older Medicare patients, said Dr. Barry M. Straube (right). Calvin Pierce/Elsevier Global Medical News

Invest Wisely in Information Technology

One of the barriers to systematically measuring quality for physicians, especially those in small practices, is the cost of electronic health records and other technology.

“Don't waste a lot of time and money on high-tech solutions,” advised Dr. Kevin B. Weiss, professor of medicine at Northwestern University, Chicago, and chair of the ACP's performance measurement subcommittee.

Dr. Weiss, who said he considers himself a believer in health information technology, cautioned that many of the first- and second-generation EHRs were not designed for population-based medicine, which is essential for participation in pay-for-performance programs. Instead, the systems were built to mimic paper records and to work with individual patients.

Consider investing in EHRs that have population-based care functionality, or look into cheaper alternatives, he said. A lower-cost option is to use patient registries, he said. Patient registry software allows physicians to track their management of patients with chronic health conditions and to report on process and outcomes data that may be required by pay-for-performance programs.

One way to get ready for the pay-for-performance movement that does not involve any technology is to get in the habit of having weekly discussions with staff on quality issues, Dr. Weiss said. Physicians can also consider investing in team-oriented continuing medical education courses, he said.

PHILADELPHIA — The effect that any future Medicare-run pay-for-performance program would have on primary care physicians is still very much up in the air, experts said at the annual meeting of the American College of Physicians.

Medicare currently has no pay-for-performance programs in effect, and—although the agency has various demonstrations and pilots underway to look at this issue—the real effect of such a program is still a matter of speculation, said Dr. John Tooker, ACP's executive vice president and chief executive officer.

But Dr. Tooker urged physicians to consider participating in what may be a precursor to a Medicare pay-for performance program: the Physician Voluntary Reporting Program. The initiative, launched earlier this year by officials at the Centers for Medicare and Medicaid Services, asks physicians to report on a core starter set of 16 quality measures. There is no funding attached to the program at this point.

“It's a good way to begin to learn how to do this in your practice,” Dr. Tooker said. “But most importantly, I think it's really a matter of learning to change the culture of a practice.”

If done right, pay-for-performance programs could result in higher quality patient care and increased physician and patient satisfaction, said Dr. C. Anderson Hedberg, ACP's immediate past president.

But the ACP is concerned that such programs could also lead to increased paperwork burdens, higher expenses, less revenue, and time taken away from patient care, he said. And there could be unintended consequences for sicker and noncompliant patients. Much will depend on what measures are used, how quickly they are phased in, how data will be collected, the type of public reporting involved, and the incentives applied, he said.

ACP officials aren't the only physicians who have questions about how pay-for-performance programs—whether through Medicare or private insurers—will affect their practices. At the ACP's town hall meeting on the issue, Dr. Emily R. Transue, an internist in a group practice in Seattle, said there is still not a set of consistent and appropriate quality measures that everyone has agreed to use. For example, she received two reports on her performance from two different companies. In one report she was rated as a high performer, and in the other her quality of care was considered below average. “Clearly there's something that isn't fitting together,” she said.

If physicians can't come up with appropriate quality measures, these programs will end up just being another set of hoops that physicians have to jump through, she said.

Dr. Teresa M. Schaer, a geriatrician at St. Peter's University Hospital in New Brunswick, N.J., said she would like to see measures that are on topics of importance to Medicare beneficiaries, such as counseling about end-of-life planning. When she spends 40 minutes discussing such preferences with a patient who has Parkinson's disease, she would like to see such counseling recognized as high-quality care.

Dr. Barry M. Straube, acting director of the Office of Clinical Standards and Quality at CMS, acknowledged that some of the measures the agency has been focused on may not be relevant to older Medicare patients. Officials at CMS have been discussing how to assess quality care in special populations, he said.

But the ongoing quality work is being done in collaboration with Medicaid and commercial health plans, so for now the focus is on measures that apply to a broad population, Dr. Straube said.

One program that has been a pioneer in this area was formulated by the Bridges to Excellence coalition, which was founded by a number of larger employers and offers incentives to physicians who demonstrate quality care. To date, the program has shown that in communities where incentives are available, there has not been patient dumping, said Francois deBrantes, national coordinator of the program. “That's not how good performance is achieved.” In fact, after physicians devoted time to reengineering their practices, they generally sought out more patients, he said.

Officials with the program have also found that the financial incentives are effective, and that the size of the incentive has a direct relationship to whether physicians are willing to go through an expensive and time-consuming overhaul of their practices. Asking a physician to make these changes for $1,000 a year is an insult, Mr. deBrantes said.

Incentivizing physicians to provide higher quality care has also paid off for payers, he said. They have found that patients who are managed for their chronic conditions have more office visits and fewer hospital stays, which produces an average 10% savings for payers.

But setting up incentive programs is not a small task, Mr. deBrantes said. Because incentives need to be large enough to encourage physicians to make significant practice changes, it's hard for any one employer or health plan to set up rewards programs.

It's also a major undertaking for physicians and their staffs, especially given the cost and complexity of electronic health record systems. (See box.) The transition from a paper-based practice to something more systematic takes about a year and a half with outside help, which, for small practices, is nearly impossible to make the transition without, Mr. deBrantes said.

Some of the measures may not be relevant to older Medicare patients, said Dr. Barry M. Straube (right). Calvin Pierce/Elsevier Global Medical News

Invest Wisely in Information Technology

One of the barriers to systematically measuring quality for physicians, especially those in small practices, is the cost of electronic health records and other technology.

“Don't waste a lot of time and money on high-tech solutions,” advised Dr. Kevin B. Weiss, professor of medicine at Northwestern University, Chicago, and chair of the ACP's performance measurement subcommittee.

Dr. Weiss, who said he considers himself a believer in health information technology, cautioned that many of the first- and second-generation EHRs were not designed for population-based medicine, which is essential for participation in pay-for-performance programs. Instead, the systems were built to mimic paper records and to work with individual patients.

Consider investing in EHRs that have population-based care functionality, or look into cheaper alternatives, he said. A lower-cost option is to use patient registries, he said. Patient registry software allows physicians to track their management of patients with chronic health conditions and to report on process and outcomes data that may be required by pay-for-performance programs.

One way to get ready for the pay-for-performance movement that does not involve any technology is to get in the habit of having weekly discussions with staff on quality issues, Dr. Weiss said. Physicians can also consider investing in team-oriented continuing medical education courses, he said.

PHILADELPHIA — The effect that any future Medicare-run pay-for-performance program would have on primary care physicians is still very much up in the air, experts said at the annual meeting of the American College of Physicians.

Medicare currently has no pay-for-performance programs in effect, and—although the agency has various demonstrations and pilots underway to look at this issue—the real effect of such a program is still a matter of speculation, said Dr. John Tooker, ACP's executive vice president and chief executive officer.

But Dr. Tooker urged physicians to consider participating in what may be a precursor to a Medicare pay-for performance program: the Physician Voluntary Reporting Program. The initiative, launched earlier this year by officials at the Centers for Medicare and Medicaid Services, asks physicians to report on a core starter set of 16 quality measures. There is no funding attached to the program at this point.

“It's a good way to begin to learn how to do this in your practice,” Dr. Tooker said. “But most importantly, I think it's really a matter of learning to change the culture of a practice.”

If done right, pay-for-performance programs could result in higher quality patient care and increased physician and patient satisfaction, said Dr. C. Anderson Hedberg, ACP's immediate past president.

But the ACP is concerned that such programs could also lead to increased paperwork burdens, higher expenses, less revenue, and time taken away from patient care, he said. And there could be unintended consequences for sicker and noncompliant patients. Much will depend on what measures are used, how quickly they are phased in, how data will be collected, the type of public reporting involved, and the incentives applied, he said.

ACP officials aren't the only physicians who have questions about how pay-for-performance programs—whether through Medicare or private insurers—will affect their practices. At the ACP's town hall meeting on the issue, Dr. Emily R. Transue, an internist in a group practice in Seattle, said there is still not a set of consistent and appropriate quality measures that everyone has agreed to use. For example, she received two reports on her performance from two different companies. In one report she was rated as a high performer, and in the other her quality of care was considered below average. “Clearly there's something that isn't fitting together,” she said.

If physicians can't come up with appropriate quality measures, these programs will end up just being another set of hoops that physicians have to jump through, she said.

Dr. Teresa M. Schaer, a geriatrician at St. Peter's University Hospital in New Brunswick, N.J., said she would like to see measures that are on topics of importance to Medicare beneficiaries, such as counseling about end-of-life planning. When she spends 40 minutes discussing such preferences with a patient who has Parkinson's disease, she would like to see such counseling recognized as high-quality care.

Dr. Barry M. Straube, acting director of the Office of Clinical Standards and Quality at CMS, acknowledged that some of the measures the agency has been focused on may not be relevant to older Medicare patients. Officials at CMS have been discussing how to assess quality care in special populations, he said.

But the ongoing quality work is being done in collaboration with Medicaid and commercial health plans, so for now the focus is on measures that apply to a broad population, Dr. Straube said.

One program that has been a pioneer in this area was formulated by the Bridges to Excellence coalition, which was founded by a number of larger employers and offers incentives to physicians who demonstrate quality care. To date, the program has shown that in communities where incentives are available, there has not been patient dumping, said Francois deBrantes, national coordinator of the program. “That's not how good performance is achieved.” In fact, after physicians devoted time to reengineering their practices, they generally sought out more patients, he said.

Officials with the program have also found that the financial incentives are effective, and that the size of the incentive has a direct relationship to whether physicians are willing to go through an expensive and time-consuming overhaul of their practices. Asking a physician to make these changes for $1,000 a year is an insult, Mr. deBrantes said.

Incentivizing physicians to provide higher quality care has also paid off for payers, he said. They have found that patients who are managed for their chronic conditions have more office visits and fewer hospital stays, which produces an average 10% savings for payers.

But setting up incentive programs is not a small task, Mr. deBrantes said. Because incentives need to be large enough to encourage physicians to make significant practice changes, it's hard for any one employer or health plan to set up rewards programs.

It's also a major undertaking for physicians and their staffs, especially given the cost and complexity of electronic health record systems. (See box.) The transition from a paper-based practice to something more systematic takes about a year and a half with outside help, which, for small practices, is nearly impossible to make the transition without, Mr. deBrantes said.

Some of the measures may not be relevant to older Medicare patients, said Dr. Barry M. Straube (right). Calvin Pierce/Elsevier Global Medical News

Invest Wisely in Information Technology

One of the barriers to systematically measuring quality for physicians, especially those in small practices, is the cost of electronic health records and other technology.

“Don't waste a lot of time and money on high-tech solutions,” advised Dr. Kevin B. Weiss, professor of medicine at Northwestern University, Chicago, and chair of the ACP's performance measurement subcommittee.

Dr. Weiss, who said he considers himself a believer in health information technology, cautioned that many of the first- and second-generation EHRs were not designed for population-based medicine, which is essential for participation in pay-for-performance programs. Instead, the systems were built to mimic paper records and to work with individual patients.

Consider investing in EHRs that have population-based care functionality, or look into cheaper alternatives, he said. A lower-cost option is to use patient registries, he said. Patient registry software allows physicians to track their management of patients with chronic health conditions and to report on process and outcomes data that may be required by pay-for-performance programs.

One way to get ready for the pay-for-performance movement that does not involve any technology is to get in the habit of having weekly discussions with staff on quality issues, Dr. Weiss said. Physicians can also consider investing in team-oriented continuing medical education courses, he said.

The report is available online at www.census.gov/prod/2006pubs/p23-209.pdf

Americans age 65 and older are living longer with fewer disabling health problems, according to a report from the U.S. Census Bureau.

The decline in disability is partly due to increased education levels among seniors, better treatments for cardiovascular diseases, and improvements in the management of chronic conditions, Richard M. Suzman, Ph.D., associate director of behavioral and social research for the National Institute on Aging said at a press briefing sponsored by the National Institutes of Health.

“Education is a particularly powerful factor in both life expectancy and health,” Dr. Suzman said.

The report, “65+ in the United States: 2005,” draws on existing data to examine the growth of the senior population, longevity and health, economic characteristics, geographic distribution, and social characteristics. The National Institute on Aging, a part of the National Institutes of Health, commissioned the report.

Census officials predict that the number of people age 65 and older will double within the next 25 years, leaving policy makers with more decisions to make on how to pay for and provide care to the senior population.

By 2030, nearly one of every five Americans–about 72 million people–will be 65 or older, said C. Louis Kincannon, director of the U.S. Census Bureau, and already the fastest-growing segment of the U.S. population is seniors age 85 and older.

But if current trends are any indication, those seniors could experience less disability from disease. A number of surveys compiled for the census report show a decline in disability among seniors over the past two decades. For example, one study estimated the level of disability at about 20% in 1999, compared with 26% in 1982.

Studies that assess instrumental activities of daily living, such as cooking, light housework, and using the telephone, show declining trends in disability. However, studies evaluating activities of daily living such as bathing, eating, and dressing show mixed results, according to the report.

Evidence from four surveys shows that about 20% of seniors have chronic disability, 7% to 8% have severe cognitive impairments, and about 30% experience difficulty with mobility.

“There still is a huge burden of disability once you look at the oldest old group,” Dr. Jane F. Potter, president of the American Geriatrics Society, said in an interview.

Prevention, including encouraging older patients to exercise regularly, is key in combating disability from chronic conditions, said Dr. Potter, who is also the section chief of geriatrics and gerontology at the University of Nebraska in Omaha.

About 80% of seniors have at least one chronic health condition and half have at least two chronic conditions.

Arthritis and heart disease are among the top chronic conditions affecting seniors. In 1998–2000, 19.3% of people age 75 years and older and 11.8% of those age 65 to 74 had activity limitations caused by arthritis and other musculoskeletal conditions. Heart and circulatory diseases affected 11.1% of seniors age 65 to 74 and 17.1% of seniors age 75 and older, according to data collected between 1998 and 2000.

Improvements in socioeconomic and living conditions in the first part of the 20th century and more recently advancements in public health and biomedical research have led to improvements in U.S. life expectancy. Life expectancy in the United States has reached 76.9 years, compared with 47.3 in 1900 and 68.2 in 1950.

But there are still racial differences in life expectancy, and the United States is lagging behind other populous countries, especially Japan and some Western European countries.

Continued progress on life expectancy will require advances in the prevention and treatment of heart disease, improved knowledge of the genetic links to cancer, and the need to adopt healthy lifestyles, according to the report.

The census report also analyzed how seniors were receiving medical care and other support. Individuals age 65 and older were less likely to have a regular source of medical care than younger people. And seniors were more likely to seek care at the emergency departments. The highest rates of emergency department use were among people age 75 and older, according to the report.

Among long-term care arrangements, home and community-based care is the most common. About 70%–80% of noninstitutionalized seniors receive care from friends and family, frequently with help from a paid provider. But more than 65% of seniors who are noninstitutionalized depend on unpaid help only. Those who receive paid care generally get fewer hours of care per week, according to the report.

Another trend in long-term care is the use of assisted living facilities. A 1999 survey found that more than 800,000 people age 65 and older were living in assisted care facilities, and more than half reported no chronic disability.

“We're in totally unchartered territory,” Dr. Jonathan M. Evans, chief of geriatrics and palliative medicine, University of Virginia, Charlottesville, said in an interview.

One of the biggest concerns, Dr. Evans said, is that there will not be enough paid caregivers in 20 years or so to meet the needs of the older population, based on current projections. “We will have to fundamentally rethink the way care is provided,” Dr. Evans said.

But it could be an opportunity, he said, to get family members and volunteers involved in providing care within nursing homes and to make nursing homes a part of the community.

The report is available online at www.census.gov/prod/2006pubs/p23-209.pdf

Americans age 65 and older are living longer with fewer disabling health problems, according to a report from the U.S. Census Bureau.

The decline in disability is partly due to increased education levels among seniors, better treatments for cardiovascular diseases, and improvements in the management of chronic conditions, Richard M. Suzman, Ph.D., associate director of behavioral and social research for the National Institute on Aging said at a press briefing sponsored by the National Institutes of Health.

“Education is a particularly powerful factor in both life expectancy and health,” Dr. Suzman said.

The report, “65+ in the United States: 2005,” draws on existing data to examine the growth of the senior population, longevity and health, economic characteristics, geographic distribution, and social characteristics. The National Institute on Aging, a part of the National Institutes of Health, commissioned the report.

Census officials predict that the number of people age 65 and older will double within the next 25 years, leaving policy makers with more decisions to make on how to pay for and provide care to the senior population.

By 2030, nearly one of every five Americans–about 72 million people–will be 65 or older, said C. Louis Kincannon, director of the U.S. Census Bureau, and already the fastest-growing segment of the U.S. population is seniors age 85 and older.

But if current trends are any indication, those seniors could experience less disability from disease. A number of surveys compiled for the census report show a decline in disability among seniors over the past two decades. For example, one study estimated the level of disability at about 20% in 1999, compared with 26% in 1982.

Studies that assess instrumental activities of daily living, such as cooking, light housework, and using the telephone, show declining trends in disability. However, studies evaluating activities of daily living such as bathing, eating, and dressing show mixed results, according to the report.

Evidence from four surveys shows that about 20% of seniors have chronic disability, 7% to 8% have severe cognitive impairments, and about 30% experience difficulty with mobility.

“There still is a huge burden of disability once you look at the oldest old group,” Dr. Jane F. Potter, president of the American Geriatrics Society, said in an interview.

Prevention, including encouraging older patients to exercise regularly, is key in combating disability from chronic conditions, said Dr. Potter, who is also the section chief of geriatrics and gerontology at the University of Nebraska in Omaha.

About 80% of seniors have at least one chronic health condition and half have at least two chronic conditions.

Arthritis and heart disease are among the top chronic conditions affecting seniors. In 1998–2000, 19.3% of people age 75 years and older and 11.8% of those age 65 to 74 had activity limitations caused by arthritis and other musculoskeletal conditions. Heart and circulatory diseases affected 11.1% of seniors age 65 to 74 and 17.1% of seniors age 75 and older, according to data collected between 1998 and 2000.

Improvements in socioeconomic and living conditions in the first part of the 20th century and more recently advancements in public health and biomedical research have led to improvements in U.S. life expectancy. Life expectancy in the United States has reached 76.9 years, compared with 47.3 in 1900 and 68.2 in 1950.

But there are still racial differences in life expectancy, and the United States is lagging behind other populous countries, especially Japan and some Western European countries.

Continued progress on life expectancy will require advances in the prevention and treatment of heart disease, improved knowledge of the genetic links to cancer, and the need to adopt healthy lifestyles, according to the report.

The census report also analyzed how seniors were receiving medical care and other support. Individuals age 65 and older were less likely to have a regular source of medical care than younger people. And seniors were more likely to seek care at the emergency departments. The highest rates of emergency department use were among people age 75 and older, according to the report.

Among long-term care arrangements, home and community-based care is the most common. About 70%–80% of noninstitutionalized seniors receive care from friends and family, frequently with help from a paid provider. But more than 65% of seniors who are noninstitutionalized depend on unpaid help only. Those who receive paid care generally get fewer hours of care per week, according to the report.

Another trend in long-term care is the use of assisted living facilities. A 1999 survey found that more than 800,000 people age 65 and older were living in assisted care facilities, and more than half reported no chronic disability.

“We're in totally unchartered territory,” Dr. Jonathan M. Evans, chief of geriatrics and palliative medicine, University of Virginia, Charlottesville, said in an interview.

One of the biggest concerns, Dr. Evans said, is that there will not be enough paid caregivers in 20 years or so to meet the needs of the older population, based on current projections. “We will have to fundamentally rethink the way care is provided,” Dr. Evans said.

But it could be an opportunity, he said, to get family members and volunteers involved in providing care within nursing homes and to make nursing homes a part of the community.

The report is available online at www.census.gov/prod/2006pubs/p23-209.pdf

Americans age 65 and older are living longer with fewer disabling health problems, according to a report from the U.S. Census Bureau.

The decline in disability is partly due to increased education levels among seniors, better treatments for cardiovascular diseases, and improvements in the management of chronic conditions, Richard M. Suzman, Ph.D., associate director of behavioral and social research for the National Institute on Aging said at a press briefing sponsored by the National Institutes of Health.

“Education is a particularly powerful factor in both life expectancy and health,” Dr. Suzman said.

The report, “65+ in the United States: 2005,” draws on existing data to examine the growth of the senior population, longevity and health, economic characteristics, geographic distribution, and social characteristics. The National Institute on Aging, a part of the National Institutes of Health, commissioned the report.

Census officials predict that the number of people age 65 and older will double within the next 25 years, leaving policy makers with more decisions to make on how to pay for and provide care to the senior population.

By 2030, nearly one of every five Americans–about 72 million people–will be 65 or older, said C. Louis Kincannon, director of the U.S. Census Bureau, and already the fastest-growing segment of the U.S. population is seniors age 85 and older.

But if current trends are any indication, those seniors could experience less disability from disease. A number of surveys compiled for the census report show a decline in disability among seniors over the past two decades. For example, one study estimated the level of disability at about 20% in 1999, compared with 26% in 1982.

Studies that assess instrumental activities of daily living, such as cooking, light housework, and using the telephone, show declining trends in disability. However, studies evaluating activities of daily living such as bathing, eating, and dressing show mixed results, according to the report.

Evidence from four surveys shows that about 20% of seniors have chronic disability, 7% to 8% have severe cognitive impairments, and about 30% experience difficulty with mobility.

“There still is a huge burden of disability once you look at the oldest old group,” Dr. Jane F. Potter, president of the American Geriatrics Society, said in an interview.

Prevention, including encouraging older patients to exercise regularly, is key in combating disability from chronic conditions, said Dr. Potter, who is also the section chief of geriatrics and gerontology at the University of Nebraska in Omaha.

About 80% of seniors have at least one chronic health condition and half have at least two chronic conditions.

Arthritis and heart disease are among the top chronic conditions affecting seniors. In 1998–2000, 19.3% of people age 75 years and older and 11.8% of those age 65 to 74 had activity limitations caused by arthritis and other musculoskeletal conditions. Heart and circulatory diseases affected 11.1% of seniors age 65 to 74 and 17.1% of seniors age 75 and older, according to data collected between 1998 and 2000.

Improvements in socioeconomic and living conditions in the first part of the 20th century and more recently advancements in public health and biomedical research have led to improvements in U.S. life expectancy. Life expectancy in the United States has reached 76.9 years, compared with 47.3 in 1900 and 68.2 in 1950.

But there are still racial differences in life expectancy, and the United States is lagging behind other populous countries, especially Japan and some Western European countries.

Continued progress on life expectancy will require advances in the prevention and treatment of heart disease, improved knowledge of the genetic links to cancer, and the need to adopt healthy lifestyles, according to the report.

The census report also analyzed how seniors were receiving medical care and other support. Individuals age 65 and older were less likely to have a regular source of medical care than younger people. And seniors were more likely to seek care at the emergency departments. The highest rates of emergency department use were among people age 75 and older, according to the report.

Among long-term care arrangements, home and community-based care is the most common. About 70%–80% of noninstitutionalized seniors receive care from friends and family, frequently with help from a paid provider. But more than 65% of seniors who are noninstitutionalized depend on unpaid help only. Those who receive paid care generally get fewer hours of care per week, according to the report.

Another trend in long-term care is the use of assisted living facilities. A 1999 survey found that more than 800,000 people age 65 and older were living in assisted care facilities, and more than half reported no chronic disability.

“We're in totally unchartered territory,” Dr. Jonathan M. Evans, chief of geriatrics and palliative medicine, University of Virginia, Charlottesville, said in an interview.

One of the biggest concerns, Dr. Evans said, is that there will not be enough paid caregivers in 20 years or so to meet the needs of the older population, based on current projections. “We will have to fundamentally rethink the way care is provided,” Dr. Evans said.

But it could be an opportunity, he said, to get family members and volunteers involved in providing care within nursing homes and to make nursing homes a part of the community.