Case study: Possible price tag on MU audit hits $14M

Audits of the EHR Incentive program began last year. Leland Babitch, MD, MBA, former CMIO of Detroit Medical Center (DMC), shared his experience of the process with Clinical Innovation +Technology.

Four of DMC’s sites that had attested for Stage 1 of Meaningful Use in May of 2011 received notification letters last October. The request came as an Excel spreadsheet with four questions:

1. Provide proof of possession of a certified EHR technology system, including the ONC certification and licensing agreements or invoices indicating the date of purchase and installation.
2. Provide the documentation to support the method (Observation Services or All ED Visits) chosen to report Emergency Department (ED) admissions designating how patients admitted to the ED were included in the denominators of certain meaningful use core and menu measures (i.e. an explanation of how the ED admissions were calculated and a summary of ED admissions).
3. For the Core Measures, provide the supporting documentation (in either paper or electronic format) used in the completion of the Attestation Module responses (i.e. a report from your EHR system that ties to your attestation).  Please Note:  If you are providing a summary report from your EHR system as support for your numerators/ denominators, please ensure that we can identify that the report has actually been generated by your EHR (i.e. your EHR logo is displayed on the report, or step by step screenshots which demonstrate how the report is generated by your EHR are provided.) To support Y/N attestation measures, please supply documentation such as screenshots from your EHR system.
4. Similar to #3, provide supporting documentation for the Menu Items.

Initially, DMC clarified whether the organization could provide information for all the sites together, or if they had to submit for each site individually. The auditing firm was willing to accept data and reports that were the same or similar under one copy, Babitch says.

“We thought after answering the first round we would have a second round to provide some clarification. Our answers were as specific as we thought we needed them to be given the way the questions were worded.” However, the auditors wanted more details.

For example, the second question asked whether DMC used the Observation Services or the All Emergency Department Visit method during its attestation. Babitch said he provided the answer but they wanted DMC to provide additional proof that they had used the Observation Services method to attest. “We sent all of the programming language behind how we got to our calculations,” Babitch said, “but they didn’t understand programming language.”

The auditors wanted a screen shot of a button showing that “we hit the Observation Services button as opposed to all Emergency Department Visits one. They wanted a toggle switch, but we don’t have one.”

Meanwhile, the auditors “didn’t like the fact that we were submitting reports on Core, Menu and Quality Measures as Excel spreadsheets. They expected to have a screen shot from an EMR system that showed the date a report was run, the system from which it came, some logos and other vendor identifiers. With reports exported into Excel, they seemed to think we were faking it.” DMC had to show report by report that their system natively exports its files to Excel by taking screenshots of every step.

DMC originally attested in May 2011 for the period that had just ended, and the coding wasn’t done yet, Babitch said. “If we ran reports on different days, the denominators would be up or down by three to five patients because the population kept changing as the codes changed.” The auditors didn’t understand that. “They thought if ED patients were not discharged and put in admissions or observation status, those numbers should be all the same. We demonstrated that when we reran the report 18 months later, the denominators were all the same. It took a lot of convincing.”

In fact, the fluctuating numbers eventually cost Babitch his job. He referred the auditors to a frequently asked question published as part of the information about the incentive program that said providers must simply be able to generate the reports, it’s not about the quality of the reports or attaining specific metrics. The whole issue was “not seen as a lack of education on the part of the auditors, but as incompetence on the part of DMC by upper management in Nashville.”

Another frustration centers around providers’ internal audits and compliance with standards. The auditors wanted to see the detailed audit report, not just a summary, Babitch said. “They wanted the details of every person audited, the period for which they were audited, detailed findings of any actions taken based on the audit and details of each PC throughout the organization. We have 15,000 users with thousands of PCs.”

The auditors also wanted a log of every drug-drug and drug-allergy alert that went off during the reporting period. DMC had to go back and create those logs. As part of the incentive program, DMC attested to using a drug formulary checking system. Its system did not provide alerts in that area because it doesn’t allow drugs not on the formulary to show up in the system as an option. “We couldn’t produce an audit log showing alerts for providers trying to prescribe things not on formulary. There is no alert because you can’t do it. [The auditors] didn’t understand the concept.” Eventually, DMC’s EHR vendor provided a letter explaining that hospital EHR systems are built only allowing users to prescribe drugs included in the formulary.

DMC attested early and so used a lot of its own reports rather than the canned reports its vendor later provided. “My hope is that as auditors learn more about how EHRs work, they will modify their expectations, and that vendors will change their reporting methods as they learn more about audits.”

Unfortunately, the auditing program is an all or nothing process. “If they find fault with any one portion of attestation then all of the money goes back. In the case of DMC, that’s about $14 million in that first year from Medicare.”

The DMC was among the first large hospital systems in the country to attest to Stage 1, and attaining the goals set forth by Medicare weren’t a big stretch for the system.  “We were already at a HIMSS Stage 6 prior to the announcement of the MU incentive program.  When we saw the standards, we realized that most of them were within  reach, or already had been attained by the organization.”  Because the hospitals had so greatly exceeded the goals of the program, the intensity of the audit came as somewhat of a surprise, Babitch said. 

He advises other providers to document everything and “save the documentation to the specific measure to which it applies so you have back up for later. It’s important to make sure that, from the very beginning, people associate any decisions with individual measures and metrics.” He also recommends putting all your reports in a similar format so they are easy to reference, cross-reference and find. Save logs of alerts during reporting periods so you can easily submit them. And, be able to submit full reports, not just summaries.