This article’s title was based on one of the focus topics for this issue, Electronic Health Records. However, while I was gathering my research, I received: Notice of Material Change to Your Provider Agreement from Cigna. I thought, ‘what an appropriate title for a brief commentary.’ I have more than a passing interest in both healthcare information technology and the insurance industry both being significant players in healthcare reform. Over the past eight years I have held adjunct professorships while teaching undergraduate strategic planning and marketing in the Fogelman College of Business and Economics. I also taught ambulatory healthcare in the MHA program at the College of Public Health until this past year when I resigned my faculty position as well as my position on the Healthcare Advisory Board for the MHA program. I remain on the National Board of Directors for the Medical Group Management Association and American College of Medical Practice Executives and the board liaison to the MGMA/University Relationship Committee.

The insurance industry is protected from anti-trust regulations. It enjoys protection and our lawmakers appreciate the financial support it receives. I wonder if lawmakers would react similarly in their reaction with the NRA whose Tennessee spokesman threatened to cut off their financial support and also threatened to work to get them out of office. ‘Hey boys don’t threaten to pull the trigger on our representatives and expect them to look the other way. Learning the hard way huh?’

Companies that sell services in which their growth in market share does not help protect the consumer of those services from abuse and control hurts everyone except the salesman. I have been watching different companies as they build their market share slowly but surely pull the rug out and there goes the consumer, ouch!   An amendment to your provider agreement from a company that says it routinely reviews its administrative policies and processes and tells you changes will become effective August 1, 2012, and oh by the way you have 30 days to notify it in writing from the date of the letter and it is unable to accept objections by fax or e-mail. Are you telling me that you have not bought into the electronic interchange of information, but you tell me your rules for me to get paid include electronic submission of claims? And you also strongly encourage me to use your electronic pipe for inquires on claims and for pre-certification, but you are not going to open up that pipe to make things efficient and transparent for me?  I don’t think so.  By the way, Mr. Chief Medical Officer, who signed the letter, who are you, where do you stay and what is your telephone number, what is your e-mail?  I see the bar code on your letter and the copy of the amendment you sent.  As a good friend of mine says, “work with me here.”

Dr. Susan Turney, MGMA President and CEO, recently sent a letter to Acting Administrator of CMS, Marilyn Tavenner, as the voice for the MGMA, representing 22,500 members who lead 13,600 organizations nationwide in which some 280,000 physicians providing more than 40 percent of the healthcare services delivered in the United States. The MGMA is very supportive of physician practice adoption of health information technology (HIT), however concerned about the proposed by the Medicare and Medicaid electronic health record (EHR) incentive program. The MGMA believes that if the program logistics and meaningful use requirements proposed are not substantially modified, it may result in a failure to meet the goals outlined in the American Recovery and Reinvestment Act of 2009 (ARRA) and a missed opportunity to transition large numbers of medical practices to HIT. MGMA asserts that in order to fulfill the objectives outlined in the underlying legislation, the meaningful use requirements must be achievable and verifiable without creating an undue burden on eligible professionals (EPs) and their administrative staff.  This is especially critical in the first two stages of the incentive program.  With the Stage 2 proposed rule, CMS has increased emphasis on interoperability, patient engagement, and more extensive quality measure reporting, creating an extremely demanding set of requirements that will correspond to a significant step up in capability and effort for all EPs. While ARRA outlines that the successive stages of the program are to be “more stringent,” MGMA asserts that the proposed rule goes well beyond the legislative intent. Here is a summary of key issues and recommendations:

• Medical groups are, in general, very supportive of the adoption of EHRs
• Meaningful use EHR incentive program must be fully harmonized with the e-prescribing (eRx) and Physician Quality Reporting System (PQRS) incentive programs
• CMS must fully evaluate Stage 1 before developing Stage 2 requirements
• Stage 2 objectives and measures can be reasonable and not act as a disincentive for EPs to participate in the incentive program
• CMS should avoid significantly increasing measure thresholds
• No Stage 2 objectives must require actions on the part of the patient in order for the EP to successfully participate in the program
• “Full year” reporting definition should be flexible
• No incentive program payment should be assigned in one year for activity in a previous year
• MGMA supports the proposed hardship exemptions and encourages CMS to create additional hardship categories
• MGMA applauds CMS for its provider outreach efforts and encourages a continuation of these efforts for the second stage of the program

Some EHR companies have started confusing physician groups and are ‘marketing’ their product by discussing the ‘cloud.’ According to the National Institute for Standards and Technology, “cloud computing is a model for enabling ubiquitous, convenient, on-demand network access to a shared pool configurable computing resources (e.g., networks, servers,  storage, applications and services) that can be rapidly provisioned released with management effort or service provider interaction.”  The two biggest challenges in meeting the demand are actually less about technology and more process and legal. The challenge is keeping customer data separated to keep audits in check and the right processes in place to keep the cloud scaling as it should. It takes experienced skilled workers to meet these challenges, and individuals to meet these challenges are in short supply. The Sand Hill Group says that demand for individuals with cloud computing skills has increased by 92 percent in comparison to numbers from February 2011-and is up 400 percent from the same time in 2010.

In talking with Blake Dickens of PCS Medical Solutions about where things are currently with the cloud and advice for physicians pursuing EHRs, Blake said, “PCS has done its due diligence on cloud technology and is positioned to move forward when certain issues are resolved. However, with the confusion that remains and the supply of individuals qualified in this technology and with the federal government and others snatching up these individuals faster than they can be certified, PCS is cautious. Blake said PCS is recommending that practices avoid being on the bleeding edge and that physician groups that are being pushed to the cloud by EHR companies remember the phrase, ‘the calm before the storm.’  Right now, owning your server, the software and data are in your possession and you own it, local support and security is better, and you are not at the mercy of the cloud.” All in all, he concluded that a server based system can be less expensive, has more uptime or at least be better controlled and creates ownership of the data and software.

Bill Appling, MBA, FACMPE, is president of Watkins Uiberall Health Care Consulting. He has faculty appointments at the University of Memphis in the Fogelman College of Economics and Business, where he teaches in the Masters of Health Care Administration program.

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