Conifer Family Medicine chose diabetes as its first clinical measure for the PCMH effort and recently started tracking depression screening for its diabetic patients. “We described the goals to staff and tracked progress in the registry,” Biesswanger says. “In two weeks we went from no patients screened for depression to 76 percent. I thought that was very impressive. Being able to mine that information is important, as depression can be a barrier to treatment.” She notes that clinicians also teach patients how to manage their diabetes and set attainable goals “to change the course of the disease.” Clinicians use the practice’s intranet to print diabetes information for patients at the appointment or e-mail it to them.

“Until we started with HealthTeamWorks we never realized what our EHR wasn’t doing for us. We got an EHR in 2004 but we just used it to enter patients and write notes. We learned how to build the registry, and now it’s a driving force in our patient care. We know who we’re seeing before they come in.” Proving its proficiency with the technology, Conifer Family Medicine achieved “meaningful use” of its EHR in December 2011 with the help of Mark Latta, a HealthTeamWorks health informatics consultant.

“Conifer Family Medicine’s quality improvement team is the driving force behind successful data,” coach Kelly Bowland says.  The team — Biesswanger, IT clinical supervisor Paul Patterson,  Jared Waterman, PA, and Tammy Snyder, MA — “have been working diligently to improve the processes and systems and engaging the staff in the transformation to a PCMH. They are dedicated to improving patients’ health and see the clinic succeed.”

Biesswanger – who received the Leadership Award at HealthTeamWorks’ February 2012 PCMH learning collaborative – credits the company with helping her practice “give patients better care than ever before.” She concedes, however, that working to transform the organization has not been easy.

“Training the staff to change the way they do things has been a huge challenge. There are ‘archivists’ – people who want to keep doing things the way they’ve always been done before. We’ve had a struggle retraining staff to adopt standing orders; we’re still working on written policies. But instead of forcing people, we’ve rearranged job descriptions so that we can use people in the areas of their greatest strengths.” Biesswanger notes that staff turnover does not benefit a practice. “Patients appreciate seeing the same faces every time they come in.”

She believes a key benefit of the PCMH is having all the providers practice medicine the same way. “I also think that it’s given patients the confidence that whoever they see will give them the same level of care.
“Everyone here is very excited about where we’re going – we’re trying hard to get recognition (from NCQA*),” Biesswanger says. “Family medicine will have its day, and the PCMH is the only way that’s going to happen.”

*National Committee for Quality Assurance

AgeWell Medical Associates aims to build better seniors

Part of that ambition involves the transformation into a patient-centered medical home (PCMH). AgeWell joined HealthTeamWorks’ PCMH Foundations program in August 2010. “Our founder, Dr. Jeffrey Kulp [a geriatrician], is a visionary,” says Willemyns. “He felt there was a better way to deliver primary care than being a slave to the 15-minute visit. He believes the medical community needs to become more efficient and effective. The PCMH Foundations program gave us the avenue to get there.”

Kulp says,“The PCMH concept equips primary care practices to do their part in achieving the “triple aim” of health care reform – better patient experience, population health and reduced costs.”

Measuring clinical success

With the help of HealthTeamWorks’ Quality Improvement Coach BJ Dempsey, AgeWell has made great strides. “At start of the program, 18 percent of their diabetic patients had hemoglobin A1C* measures of 9 or higher — now it’s less than 8 percent,” Dempsey says. “They used to screen 27 percent of their diabetics for depression; now they screen 99 percent. Before, only 51 percent of their patients achieved the target (geriatric) blood pressure of 140/90 or less, now 75 percent are there.”

Because the elderly often present with a variety of chronic conditions, AgeWell aims to “optimize their health, minimize the number of medications and focus on the entire person — including behavioral health,” Willemyns says. “This means depression, loneliness, substance abuse, isolation. These issues are not unique to older people, but they present confounding challenges.”

The journey to PCMH offered new challenges. “For us to have tried to do this without HealthTeamWorks — I can’t envision it,” says Lori Trivelli, AgeWell’s practice manager.  “The coaching has been invaluable. We are so grateful to have that kind of experience in our corner. Dr. Kulp’s leadership and vision, and Kathy’s role as [PCMH] champion helped us work out solutions to the challenges we encountered. PCMH work comes with tremendous culture change, but it’s gratifying to watch the team come together and focus on the complete panel of patients and the practice as a whole.”

Trivelli and Willemyns recognize that achieving PCMH status is not an endpoint. “We realize the work is never done,” Willemyns says. “We continue to set the bar a little higher and achieve new goals. As we adopt an EHR we will look at new ways to connect with patients.”

*Hemoglobin A1C is a laboratory test that indicates blood sugar control

Pediatric safety-net clinic improves asthma care with clinical registry

Community Health Services (CHS), a busy safety-net clinic for low-income children in Adams County, is a convert to the power of technology. “We can’t see a future without technology. We want to know: ‘How can we use it more?,’” says Rebecca Lusk, PNP, one of the providers. The organization adopted a clinical registry in late 2010 and “It’s been a wonderful first step for us, to use data to support the job we do. We have tightened the use of clinical guidelines, and we have seen improvement in asthma care by using flow sheets for daily [patient] management. The registry helps us know what things will be like when we get an electronic medical record (EMR).”

CHS joined HealthTeamWorks’ Patient-Centered Medical Home Foundations program in October 2010 after taking the SBIRT* training for substance abuse screening that HealthTeamWorks provides, and from technology guidance as part of HealthTeamWorks’ partnership with the Colorado Regional Health Information Organization. HealthTeamWorks Quality Improvement Coach Shelli James helped CHS establish the ReachMyDoctor patient registry, which allows a practice to monitor its care for specific patient populations — such as children with asthma.

Restructuring processes, culture to improve patient care

“The asthma flow sheet [generated by ReachMyDoctor] helps us do a thorough job,” Lusk says. “It increases the number of action plans we give out to families, reduces the number of prescription refill requests and improves our follow-up care for kids with persistent asthma.” In addition, she says, “ReachMyDoctor allows us to cross-check whether our patients have received flu shots.”

James says that the five CHS clinics in the PCMH Foundations program have made significant changes in the way they provide care for patients and their families, and for asthma patients in particular. “They hit the ground running, writing new protocols and revising tools, using their registry for planned care and completing action plans. The clinics made their medical assistants (MAs) an integral part of the team — responsible for data collection, outreach to patients, and with greater involvement in patient care. The clinics are continually examining their processes to learn how they can improve. CHS clinics are an invaluable asset to Adams County.”

Only source of primary care for many children

Nonprofit CHS was established more than 30 years ago in medically underserved areas of Adams County to provide primary and preventive healthcare services for children from birth to age 21. Nurse practitioners provide most of the care, with oversight from a part-time pediatrician. Commerce City, where five CHS clinics are located, has no private medical practices; CHS is the only medical organization that specializes in pediatrics. It also operates clinics inside two middle schools and two high schools. A sixth CHS community clinic is in Westminster, where private practices are unwilling to serve the indigent. 

“Our patient population is low-income — over 60 percent are Spanish-speaking only,” Lusk says. “Many are covered by Medicaid and CHP+; others are uninsurable and uninsured.  We offer these families assistance in applying for Medicaid/CHP+ or the CHS sliding fee. It’s also a transient population. We are the only source of primary care for some kids.”

“Accountable to the data”

In addition to the registry, HealthTeamWorks has helped CHS improve its work flow and encouraged the organization to give more responsibility to MAs, freeing time for other healthcare professionals. Lusk says that the MAs “have enjoyed the additional responsibility and greater involvement in patient care.” Because of HealthTeamWorks’ process redesign, CHS now devotes time during provider meetings for data review: “We are now accountable to the data and use it to guide us.”

Elated over their clinical progress with the registry, CHS employees “want to do more,” Lusk says. “Technology doesn’t take that much time and the benefit is apparent to providers. We hope to get an EMR so we can manage childhood obesity [ReachMyDoctor does not do this]. We want to incorporate what we’ve learned with asthma for other conditions.”

*Screening, Brief Intervention, Referral to Treatment
 

Tracking patients who visit the emergency room or need hospitalization represents an important challenge for medical practices. Because you want to ensure that your patients receive all necessary care, you want to offer follow-up services for emergent episodes. In addition, you want to learn whether ER or hospital visits could have been prevented by your intervention, patients’ self-care or patients’ awareness of appropriate ER use.                                                                                                                                                                            

Family Care Southwest, a five-provider practice in Littleton, Colo., has developed a tracking system to identify and follow patients seen at emergent facilities outside the group’s affiliated hospital system. The two physicians and three physician assistants use a spreadsheet to record such visits and follow up with patients. The spreadsheet’s columns list the reason for the hospital visit; facility; emergency department date; admission date; discharge date; first, second and third follow-up calls; when a letter was mailed; appointment date, etc.

Helen Story, MD, one of Family Care Southwest’s physicians, says, “Open communication with hospitals, hospitalists and specialists we refer to is essential for high-quality patient care. The hospital has our patient data in their system, and we know whom to call for patients’ records. We try to have good working relationships with the information technology folks at all our referral facilities, and with insurance plans, so we receive notification when our patients go to the hospital or urgent care.” She notes that patients appreciate follow-up calls from her office when they are in the hospital and after they return home from the hospital or emergency room — “They like the connection with their primary care provider, and they feel cared about.
                                                                                                                                                           
”The tracking system helps the practice stay on top of emergent episodes. “A tickler system lets us know to follow up with hospitals and specialists if we have not received a report from them within a week,” Story says. “We also use the system as a reminder for the provider or care coordinator to make follow-up calls to patients.”The practice asks nearly all patients to come in after hospitalization. “We want to let the patient know we provide quality care, review discharge medications and instructions with them and answer any questions they may have,” Story says. In addition, providers want to encourage patients not to use the emergency room to receive primary care.

“Like so many of our PCMH protocols, this effort relies heavily on the staff to maintain the tracking sheet, make the calls, gather the records, arrange the appointments, and have everything ready for the provider,” Story notes. “We encourage patients to bring a support person with them. Patients and families really appreciate the chance to sit down and understand the care they received during their stressful emergent encounter. We make it a point to discuss how to avoid future problems.

“All of us are happy that hospitals and insurance carriers are recognizing that primary-care follow-up is crucial to better outcomes. Systems are evolving: Some hospitals now notify us when one of our patients has been admitted, and most of the time the hospitalists call us when the patient is being discharged. The insurance carriers’ notifications have been a welcome addition, but many still incur some lag time. We look forward to the implementation of a statewide database for more thorough records access.”

By Marjie Harbrecht, MD
HealthTeamWorks CEO

The Multi-State, Multi-Payer Patient-Centered Medical Home (PCMH) Pilot has entered its third and final year. The 16 Front Range primary care practices that participate are striving to demonstrate financial viability and improved quality of care under a patient-centered, care-team model whose payment system blends fee-for-service, per-member-per-month and pay-for-performance strategies.

HealthTeamWorks convened the pilot in 2009 with generous funding from The Colorado Trust and The Commonwealth Fund. The participating practices comprise 83 providers and 258 staff; health plans involved in the effort are Aetna, Anthem-Wellpoint, CIGNA, Humana, UnitedHealthcare, CoverColorado and Colorado Medicaid. Participating employers include IBM in Colorado, McKesson Corp., Centura and the Colorado Business Group on Health; and hospitals owned by Centura, HealthOne, Exempla and Memorial Health Systems are also involved.

In addition to traditional healthcare services, the pilot’s compensation system pays practices to provide care coordination and care management, outreach to patients with chronic conditions and preventive care needs, and engagement of patients in their care. In the long run, changing the way physicians are paid should lower healthcare costs.

The pilot’s goals are to improve quality of care for patients with diabetes, cardiovascular disease and depression, addressing tobacco use and encouraging preventive care. It aims to reduce cost trends by decreasing hospitalizations and visits to the emergency room. It seeks to improve the healthcare experience for patients, families and the healthcare team.

Early results are impressive. For example, nearly 52 percent of diabetic patients in pilot practices are maintaining blood pressure below 130/80; the national target is 25 percent. Approximately 59 percent of diabetic patients are keeping their LDL cholesterol number below 100; the national target is 36 percent. More than 85 percent of diabetics are screened for tobacco use and over 75 percent of those who smoke are assisted in quitting. 

Patients’ satisfaction with their care in pilot practices is high. Of those surveyed, 98 percent believe they get care when they need it; 97 percent would recommend their practice to family and friends; 95 percent find their clinics well-organized, efficient and respectful of their time; and 90 percent find it easy to speak to a physician.

To help achieve these results, HealthTeamWorks provides technical assistance to PCMH pilot practices, including in-office coaching, learning collaboratives to allow practices to share their experiences and technology consultation. Our quality improvement coaches help practices implement patient-focused, team-based care to enhance access to services and apply evidence-based guidelines to improve health outcomes.

The pilot, which runs through May 2012, is being evaluated by an expert from the Harvard School of Public Health to determine the effect on quality, cost trends and satisfaction for patients and their healthcare teams. Although we are seeing some positive trends toward reducing ER and hospital utilization, it is too early to make any conclusions. We expect final results by the end of September 2012. 

We are very proud of the participating practices for their hard work and enthusiasm, and their willingness to serve as the pioneers of a new healthcare delivery system.  With results from PCMH initiatives across the country increasingly demonstrating positive outcomes, we are optimistic that practices, communities and health plans will be able to take the lessons learned and move from pilots to statewide spread and sustainability. This is the only way we will truly move the needle on achieving the Triple Aim goals: Improved individual and population health, reduced cost trends and improved satisfaction for patients and their healthcare teams. 
 

Eight staff members from practices participating in HealthTeamWorks’ Patient-Centered Medical Home (PCMH) Foundations project have received scholarships to attend the November-December Iowa Chronic Care Consortium Clinical Health Coach training in Denver.

The scholarships cover up to 75 percent of the $1,200 tuition. The clinical health coach program builds care management strategies, enhances leadership and communication skills and develops coaching skills to improve health, clinical and behavioral outcomes and business efficiency.

Scholarship recipients are: 

• Sheri Bishop, medical assistant – Spruce Street Internal Medicine, Boulder;

• Megan Green, RN – Altitude Family & Internal Medicine, Littleton;

• Beth King, practice manager – Associates In Family Medicine, Lemay office, Fort Collins;

• Crystal Fuentes, medical assistant – Associates in Family Medicine, West office; Fort Collins; and

• Amy Johnson, RN, Associates in Family Medicine, Foxtrail office; Loveland.

“I’m so excited to go through this training and make our practice more dynamic,” says Beth King. “Learning how to better reach patients and give them more tools to advocate for their own health, and become a liaison for them, our providers and our whole community, I believe is going to be a very valuable asset to improving the health of our patients.”

HealthTeamWorks’ Quality Improvement Coach Niki Hyde, MEd, MS, HSAM, attended the training in Iowa in September and October. “It was a transforming experience for me — I learned unexpected things about my communications style,” she says. “I feel I’m on the road to developing a whole new skill set.”

Quality Improvement Coach Shelli James will also attend the November-December training in Denver.

Attention to detail, the ability to form cordial relationships with both healthcare providers and patients, and competence in juggling multiple tasks at once are the key attributes of a care coordinator, according to Mackenzie Bell, MPH.

Bell has served as the care coordinator at Belmar Family Medicine in Lakewood, Colo., since June. The practice is one of 16 primary care clinics chosen in 2009 to participate in the Colorado Multi-Payer Patient-Centered Home (PCMH) Pilot, a four-year program convened by HealthTeamWorks. The PCMH pilot is one of many national endeavors initiated to demonstrate financial viability and improved quality of care.

Care coordination is a fundamental component of the medical home. It ensures that individual patients and specific patient populations, such as diabetics, get necessary services and information beyond the practice, and that all providers involved know patients’ care plans and the results of tests, procedures and consultations. The care coordinator ties together the connections to the “medical neighborhood” so all aspects of care are addressed — physical, emotional and social — and services aren’t duplicated.

For Bell, “Care coordination is a good mix of public health and clinical interaction, working with providers and patients with chronic conditions.” She is using her master’s degree in public health and appreciates the clinical effects of her work, as she is currently in nursing school. “I enjoy the patient contact and pulling everything together from my background,” she says. “I enjoy dealing with data, reporting clinical measures [for the PCMH program], being a liaison between patients and providers.”

Bell is establishing the Passport2Health coaching program, which sprang from the health coaching efforts at Westminster Medical Clinic. Passport2Health will assist patients needing extra attention in managing chronic conditions. In five one-hour visits, Bell will meet with each person to set health goals, discuss exercise and nutrition, answer questions and get her/him engaged in self-care. “I’m there for patients; I support and empower them. I help them along the way to achieve better health,” she says. “That face-to-face contact is important.”

“Mackenzie is able to focus on issues that neither the physicians nor I as practice manager have time to do,” says Judy Hewitt, Belmar practice manager. “The most important role she plays is to organize, plan, supervise and conduct self-management programs for our patients who need extra help. She is constantly looking for new resources for our patients and ensures that medical records are complete and up to date. She watches due dates for services and contacts patients to come into the office to receive them, and collects data on services done outside our office.” 

In addition to establishing Passport2Health and handling the care coordination needs of patients referred by Belmar physicians Tracy Hofeditz, MD, and Kristin Everett, MD, and nurse practitioner Tracy Youse, Bell facilitates quarterly group visits for the practice’s diabetes patients. As part of her PCMH responsibilities, she contacts diabetes and cardiovascular disease patients whose clinical measures raise concern, asking them to come in for lab work or a provider visit.

“Mackenzie is learning and maturing in her position as we mature at Belmar Family Medicine as a medical home,” says Hofeditz. “As leader of our weekly PCMH meetings, she keeps us on track with the many initiatives under way such as group visits, the Passport2Health self-management program, and the ongoing definition of our medical neighborhood. She manages our ever-growing amount of population data, collecting and reporting them for our team-based quality-improvement work. Her flexibility, creativity and ability to adapt have been critical to our success.”

Bell says her biggest challenge is “that the care coordinator position isn’t well-defined. There’s no place you can get training. I sort of work by hearing what others are doing.” Still, Bell says she enjoys her position and Belmar Family Medicine. “I feel very supported — I’m having a wonderful time.”

Beth Neuhalfen, PCMH project manager at Westminster Medical Clinic, developed the health coaching program. (A similar effort, Passport to Health, is being launched in Lakewood’s Belmar Family Medicine with help from Caitlin Barba, Westminster Medical Clinic’s practice manager.) “I had done health coaching at [another medical home] and I wanted to align this program with our mental health effort — Advancing Care Together (ACT) — so patients could get health coaching and mental health care. We strive to be a full-service practice,” Neuhalfen says. Under ACT, the practice has a licensed clinical social worker on site three days a week to provide mental health treatment. 

Physicians determine which patients are appropriate for health coaching — perhaps a diabetic having difficulty fitting exercise into her schedule, an overweight man who doesn’t understand good nutrition or a woman with cardiovascular disease who doesn’t recognize the dangers of high blood pressure. The physician introduces the patient to Neuhalfen and explains the help she can offer. “I’ve never had anyone not sign up for the program,” Neuhalfen says. “I encourage spouses to come because you will be more successful if you attend with the person you live with.”

Insurers cover coaching under "800 rule"

Most insurance companies cover health coaching visits under the “800 rule” created by the Colorado Medical Society in 2010 and adopted by the state legislature. The rule allows unlicensed healthcare personnel to provide certain services with a physician’s direction. Ideally, the program will pay for itself. Westminster Medical Clinic uses CPT* code 98960 to bill for the visits (the patient must have an accompanying diagnosis). Neuhalfen has hired a full-time health coach to help her; insurance reimbursement should cover the salary.

Westminster Medical Clinic has enrolled 25 adult patients in health coaching since the program started in September. Their diagnoses include diabetes, cardiovascular disease, metabolic syndrome, obesity and asthma. The program’s goal “is to take pressure off the providers,” Neuhalfen says. “They don’t have the time to spend an hour with every patient to teach them about their conditions. Coaching is about reaching patients’ goals. Patients often repeat what the doctor wants them to say [about their health goals], but it’s not necessarily what they want. People are more likely to achieve a goal if it’s their goal.”

Patients' goals are the goals that matter

For example, one obese patient told Neuhalfen that he wanted to lose weight to achieve his dream of piloting an airplane. A woman with metabolic syndrome said, “I want to be there for my grandchildren.” At each visit, the health coach reviews the patient’s progress toward goals and together they may set new ones.

“Health coaching isn’t technical,” Neuhalfen continues. “It’s giving patients the tools they need to live a healthy lifestyle. We give them a roadmap, and often they’re amazed at how easy it is. They just didn’t have the right information.”
 

*current procedural terminology
 

Patient Advisory Committee ensures that PCMH Pilot practices respond to patients’ needs

A medical home can’t be patient-centered without listening to its patients. That’s what the HealthTeamWorks Patient Advisory Committee is for.

HealthTeamWorks established the committee to improve customer service, patient support and the engagement of patients in their care. Its 14 members, recruited from the 16 primary care practices participating in the Colorado Patient-Centered Medical Home (PCMH) Pilot, meet monthly. The group informs patient-related issues such as the development of self-management support material or letters describing the practices’ services. Kari Loken, Systems Transformation Project Manager, facilitates the committee.

“I think that the committee members are all dedicated to helping their practices be better. They like helping people feel comfortable getting medical care,” says Boyd Adams, 64, retired from careers in the Army and financial planning. Adams, who lives in Castle Rock, is a patient at Lone Tree Family Practice. He joined the Patient Advisory Committee at the urging of Chris Linares, MD, his primary care physician.

Committee member Pat Schmidlapp, 64, a Parker resident and a patient at Mountain Top Family Health, became a PCMH advocate when electronic transfer of her medical records from practice to hospital facilitated her care after a serious car accident. “When my doctor told me about the [PCMH] pilot, I thought, ‘here’s something that could be beneficial in a big way.’ As patients, we don’t always feel we have a voice; we often get shut down by old provincial ways of doing things [in medicine]. In the PCMH, doctors and nurses and receptionists listen to what patients have to say.”

Committee members listen to each other, too. “We come from different areas, have different kinds of jobs, but we work with a bigger perspective [than our own backgrounds], says Kathy Helm, 60, senior administrative assistant at the Colorado Health Institute and a patient at Westminster Medical Clinic. “Anyone can speak, everyone listens and we get a lot done.” Helm emphasizes the importance of helping other patients understand the PCMH and how it differs from a traditional medical practice.

Schmidlapp says that part of the committee’s work is teaching people to be better patients. “They need to realize there’s a responsibility on their part.” For example, a patient who can describe symptoms in detail, note what medication she took and when, and give an accurate medical history saves time for her care-givers and helps improve the quality of the care received. “We’re patients educating patients,” Schmidlapp says of the committee.

The group’s members may help their PCMH practices beyond the committee. For example, Linares has asked Adams to help develop Lone Tree Family Practice staff’s potential by conducting personality profiles and individual counseling. “Are their personalities best suited for the jobs? I hope to help them let their work turn them on and to make them feel good about what they’re doing,” Adams says. Schmidlapp gives presentations to medical groups around Colorado on the benefits of the PCMH on behalf of HealthTeamWorks. “The PCMH movement is growing, and you can’t change something if you don’t want to get involved,” she says.
 

Trail-blazer. Pace-setter. Pioneer. Early adopter. Whatever you call it, Miramont Family Medicine in northern Colorado seizes opportunity and welcomes change. The eight-physician practice, with two locations in Ft. Collins and one in Wellington, was among the first in the state to attest for the Medicare Electronic Health Record (EHR) Incentive Program and receive payment a month later.

It was exciting,” acknowledges Miramont founder John Bender, MD, FAAFP. “We made sure we got enrolled in the incentive program as soon as we could (in January), started collecting data and attested after [the requisite] 90 days — in late April. We received our first payment in mid-May.”

Miramont embraces technology

While other practices are still mulling their approach to attaining “meaningful use” of their EHRs as defined by the Centers for Medicare & Medicaid Services, Miramont wasted no time. “We were smart enough to select an EHR that CORHIO recognizes,” Bender says. CORHIO — the Colorado Regional Health Information Organization — leads the Colorado Regional Extension Center (CO-REC), whose partner organizations (including HealthTeamWorks) provide in-depth guidance on optimizing office processes to maximize the benefits of electronic systems, improve the quality of patient care and help providers meet federal meaningful-use guidelines.

Miramont embraced health information technology early on. The practice is on its second EHR, an e-MDs system acquired in 2007. Although the technology cost the practice $200,000, “in the last four years we’ve seen efficiency go up and costs come down,” Bender says. “We received our formulary bonus and now we’ve received our Medicare incentive program bonus. We’ve transitioned into the business of quality.”

Because the practice is experienced with using an EHR, it was already doing a lot of meaningful-use activities, Bender says. These include using computerized physician order entry for at least 80 percent of all orders, submitting claims to payers electronically and giving patients electronic access to lab results. While billing and coding staffers Tina Smith and Julie DeSaire ensured the manual reporting and data entry into the CMS website on behalf of the physicians, a clinical team lead by Clinic Director Amanda Cline and Medical Director Kelly Lowther, MD, kept the meaningful-use effort on track.

Tips to achieve meaningful EHR use

Bender offers a few pointers for other practices intent on achieving meaningful use:

• Purchase a certified EHR recognized by CORHIO for meaningful-use application;
• Get free assistance from CO-REC in using your EHR to meet meaningful-use requirements;
• Establish a patient portal to provide online access to appointment scheduling, test results, insurance and demographic information-capture and healthcare information;
• Establish a patient registry to assist with the care of specific patient populations;
• Enroll in PECOS (Medicare’s internet-based Provider Enrollment, Chain and Ownership System); and
• Begin collecting the data that CMS requires.

“We had to incorporate the meaningful-use work into our PCMH* planning,” Bender says. “We attended conferences [on meaningful use] given by the state and national American Academy of Family Physicians. We created a list of meaningful-use deadlines and worked it actively. We managed the project on a weekly basis.” That drive and attention to detail paid off.

However, “The meaningful-use incentive money is not a sufficient enough reason for practices to pursue electronic records,” Bender says. “There has to be a desire to use the technology to increase efficiency, enhance patient safety and improve the quality of healthcare in order to have overall success.”

*patient-centered medical home