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ASCs Face Unique Meaningful Use Challenges—Understanding the 50% Rule and How to Respond
By Sean Benson

Twenty-seven billion dollars in potential incentive payments would make any industry take action. When coupled with steep future penalties for noncompliance, the stakes for achieving meaningful use (MU) go even higher.

As momentum increases within the physician community to position itself to receive stimulus dollars, a number of unique complexities have surfaced pertaining to the relationship between this group and ambulatory surgery centers (ASCs).

One of the most challenging is that ASCs are not eligible to receive stimulus dollars, something few expect will change under the present economic and political climate. Because they have been left out of the MU incentive equation, there has been no reason for ASCs to invest in certified EHR technology—one of the central requirements physician practices must meet to receive incentive funds.

This reality forms a problematic foundation for ASCs with regard to a little-known clause in the regulations referred to as the 50% rule, which requires that at least one-half of a physician’s patient encounters take place at facilities equipped with certified EHR systems. This rule is placing enormous pressure on some ASCs to make costly technology decisions to ensure they do not lose their physician base—decisions that could have far-reaching impact on workflow and productivity.

The race for dollars is on. Hospitals and eligible professionals, including physicians, began applying for MU incentive payments in April, and the first payments went out in May. Physicians are focused on moving forward with implementing appropriate technology and are also looking to ASCs to provide an infrastructure that will ensure they meet MU criteria. 

But ASCs need to be careful about making rash decisions that could equate to costly mistakes, especially since most EHRs are not designed to accommodate their unique workflow and data needs. Both providers and ASCs need to understand the full picture and take a careful, thoughtful approach to choosing systems that align with operational needs and future expectations.

The 50% Rule
ASCs may not be part of the MU discussion as it pertains to incentives or penalties, but they are becoming increasingly aware of what physicians face in their quest to comply. The 50% rule in particular is generating contention between ASCs and their physicians as they struggle to decide whether facilities will ultimately have to deploy certified EHR technology for their physicians to meet MU requirements.

According to the Centers for Medicare and Medicaid Services (CMS), ”any eligible professional demonstrating meaningful use must have at least 50% of their patient encounters during the EHR reporting period at a practice/location or practices/locations equipped with certified EHR technology capable of meeting all of the meaningful use objectives.”

It has included ASCs in its definition of a “practice/location.” Plus, the CMS has specified that the term “equipped” refers to the need to have technology available to support use of a certified EHR to satisfy all of their MU objectives.

Because some physicians and specialties may have a large share of their patient encounters occurring at an ASC, this clause may result in these facilities being pressured to adopt certified technology. What is often overlooked in the process, though, is that the technology is not a good match for an ASC’s workflow nor were these systems developed with the nuances of an ASC in mind. Plus, there will be no incentive dollars flowing to an ASC to alleviate the high costs of the technology, not to mention the cost of changing administrative and operational procedures to align with the technology.

The Workflow Dilemma 
Consider that when a patient enters a physician office, there will likely be continuous follow-up care, referrals for diagnostics or to other specialists, and regular tweaks to care to accommodate the dynamic needs of a patient over time. It’s a longitudinal approach to care, and MU criteria were rightfully designed to move the industry in this direction to support the efficient electronic capture of patient data over the course of treatment.

Achieving MU certification hinges on an EHR’s ability to meet this need in a physician practice. With this in mind, vendors have designed products to capture patient information over the course of many encounters.

It is a workflow that fits well in a physician office environment, but an ASC is much different. ASC workflows revolve around procedures and the data captured specifically addresses the needs of a particular procedure being performed.

One primary difference in these two workflows is that an ASC will not require the extensive evaluation that may occur in a physician office. Thus, utilizing an EHR designed to capture data for MU will create additional, unnecessary work for an ASC’s administrative and clinical staffs, including physicians.

That evaluation is just one of many considerations. MU compliance also requires other activities that are not typically part of the ASC workflow, including the following:

• computerized provider order entry;
• drug/drug interaction checking;
• drug formulary checking;
• e-prescribing;
• reconciling medications;
• incorporating clinical lab results into the EHR;
• calculating and reporting clinical quality measures to the CMS;
• providing clinical summaries to patients;
• submitting data to immunization registries and public health agencies; and
• keeping problem lists, medication lists, and medication allergy lists updated.

To be a meaningful user, either an ASC or a physician’s office will have to significantly change its workflows to meet these requirements.

What Can Be Done
There are a number of considerations that should come into play before an ASC yields to the pressure to adopt a certified EHR product. First, an analysis should be completed for each physician to determine where patient encounters, which the CMS defines as the provision of medical treatment and/or evaluation and management services, are occurring. In many instances, the 50% rule will be of no consequence to an ASC because a physician may see most of his patients initially in the office. For situations where more than 50% of patient encounters occur at the ASC itself, the following courses of action can be taken:

• An ASC can make a substantial investment in a certified EHR product and subsequent workflow changes.

• ASCs can provide technical connectivity that allows physicians to access an office’s certified EHR from the ASC.

• Physicians can change the way patient activity is scheduled so that the majority of encounters are taking place in the office or other setting where a certified EHR is in use.

Considerations Going Forward
While the desire to meet the needs of an existing physician base will play an important role in how ASCs approach the current stir over the 50% rule, the fact remains that there is little incentive for them to comply with MU requirements. Establishing a strong relational foundation with a physician base is crucial to ASC success, which raises the stakes regarding decisions on whether or not to invest in certified systems.

It’s important to note that the choice to provide access to a certified EHR will not necessarily ensure that physicians are in compliance either. MU requirements clearly state that simply having the technology is not enough—they have to demonstrate its appropriate use.

The larger issue, of course, is the lack of funding being provided to ASCs for this effort. It would be a strategic move on the part of ASCs to have a united front and voice in this matter going forward, as there will be many challenges ahead if the expectation is that they equip themselves with certified EHR systems. Creating a dialogue with the CMS will be an important first step to make the potential issue known and begin exploring solutions.

If MU requirements are going to be extended to the ASC environment, then the same incentives available to others falling under the directives should be available to these healthcare organizations as well. 

— Sean Benson is cofounder and vice president of consulting with ProVation Medical, part of Wolters Kluwer Health.