This report originally appeared in the February 2011 issue of DOTmed Business News

The two agencies responsible for managing the carrot and the stick of the electronic health records incentive programs announced those programs were ready on January 3. That Monday marked the official registration kickoff for eligible hospitals and health care professionals who are looking to reap the benefits of Medicare and Medicaid EHR incentives.

The Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology didn’t have to wait long to reward the first providers for the successful adoption and implementation of a certified EHR. Just two days after registration opened, two physicians in Oklahoma received payments of $21, 250 each as part of the Medicaid EHR incentive program.

Whether providers like it or not, they must get onboard with the unprecedented push for health IT in order to stay competitive. But it’s not just staying competitive that should fuel the IT compliance fire: failure to demonstrate meaningful use of EHRs will result in Medicare penalties come 2015. Even though there’s still years to go, physicians aren’t wasting any time. Providers spent more than $88.6 billion in 2010 on developing and implementing EHRs and other HIT projects, according to a report by PricewaterhouseCoopers Health Research Institute.

“There is nothing comparable to what is being done on a national level with incentives and penalties that has happened in health care IT in the last 50 years,” says Dr. Vinay Vaidya, chief medical information officer with Phoenix Children’s Hospital in Arizona.




Consequently, last year was a strong one for health IT vendors. “We’ve seen significant growth in our consulting service to help with the process of transformation and for our customers to achieve meaningful use,” says Gerry McCarthy, vice president and solutions line manager, physician solutions, with McKesson Provider Technologies. “It’s been one of the hottest service programs that we’ve offered in the past 18 months.”

Siemens Healthcare’s Health Services unit also experienced a bump — business was up by about 29 percent in 2010, says Luis Castillo, the unit’s senior vice president. In addition to EHR software and consulting offerings, health care business intelligence solutions have been a source of growth for the company.
With the wide range of products and services, many hospitals have the necessary tools to reach stage one measures, but some are finding that with meaningful use, the devil’s in the details.

Stage one: are you ready?
With the 2011 deadline for stage one meaningful use incentives inching closer, there’s a lingering question about hospitals’ readiness to meet the objectives. In a June 2010 survey of 120 chief information officers by PricewaterhouseCoopers Health Research Institute, eight in 10 hospital CIOs said they were concerned or very concerned about meeting meaningful use requirements. CIOs said they were worried about the lack of clarity on final meaningful use rules and a shortage of qualified staff to implement the technology.

In November 2010, the percentage of CIOs who expected their facilities to qualify for stage one meaningful use incentives dropped by half in comparison to previous estimates, according to a survey by the College of Health Information Management Executives. Just 15 out of 191 of those who were surveyed said they were confident about qualifying for the incentives in the first half of federal fiscal year 2011.

And yet, survey data released earlier this year show a significant number of hospitals and physicians intend to adopt EHRs and qualify for the incentives. Four-fifths of the nation’s hospitals and 41 percent of office-based physicians plan to get on the HIT train, according to ONC data. About two-thirds of hospitals said they will apply for stage one incentives in 2011-2012.

At this point, it may not be a matter of technology, but time. “If organizations are looking at achieving meaningful use within the time allotted for stage one, many of the hospitals that are mature will certainly make that threshold,” says Edna Boone, director of healthcare information systems with the Healthcare Information and Management System Society. “Most organizations already have goals that align with meaningful use within their strategic plans and IT plans. The stretch is really in the timing of achieving these goals in order to achieve the incentives.”

CPOE adoption within reach
Depending on facility size and resource availability, providers will run into different challenges on their road to demonstrating meaningful use. In recent surveys, many hospital CIOs expressed concerns about computerized provider order entry, a core measure of stage one objectives. In order to demonstrate CPOE for the first stage, more than 30 percent of all unique admitted patients with a minimum of one medication in their list must have at least one medication order entered using CPOE.

Although CPOE was initially considered a major hurdle for hospitals in meeting stage one objectives, today, providers can breathe a little easier. “CPOE thresholds for meaningful use for stage one were lowered significantly, so we’re not seeing that as big of a concern as it was when the initial criteria were released,” says Boone.

For the final criteria, any licensed health care professional authorized to enter orders into the medical record per state, local and professional guidelines can use CPOE for medication orders, broadening the initial requirement from just physicians. Providers can also include medication orders for patients admitted to the emergency department. “We believe most organizations could hit that threshold just by implementing CPOE in the emergency room,” says Boone.

Hospitals that have successfully implemented CPOE and have a high adoption rate say the accomplishment puts them in a very strong position for qualifying for Medicare and Medicaid EHR incentives right away.

Phoenix Children’s Hospital has been using CPOE on the inpatient side since 2009, although it attempted to implement it much earlier. In the early 2000s, a combination of factors stood in the way: “The vendor systems were not mature enough and the clinical population was not that receptive,” says Vaidya. Today, the successful adoption of CPOE in the hospital gives a boost to the acceptance of other health IT additions necessary for meaningful use.

Physicians at Phoenix Children’s were impressed by the capabilities of CPOE as soon as it went live. Prior to the implementation, finding out how frequently a particular medication was prescribed would take days – CPOE allows for a nearly instantaneous answer and offers additional details, like which physicians ordered the medicine, in what departments and for what patients.

Prior to CPOE, hospital staff resisted every attempt to add automation to the clinical process, says Bob Sarnecki, vice president and CIO with Phoenix Children’s. “Now that we’re on CPOE, when we add additional components electronically to what we’ve built already, physicians see those as enhancements to the system they’re already using, instead of an automation process that challenges their time with the patients or in providing direct clinical care,” he says.




Plus, correctly implementing CPOE makes the health IT provisions outlined in the American Recovery and Reinvestment Act of 2009 much less daunting to the average clinician, says Sarnecki, as the adoption process covers vital automation basics. “If you’re already automated, ARRA is not scary. If you haven’t done any automation, then ARRA means you have to look the CPOE beast right in the eyes,” he says.

Other meaningful use hurdles
While most major facilities have already faced the CPOE “beast,” some issues remain with a few other required stage one features. The Christ Hospital in Cincinnati, Ohio has been using EHRs since 2008 and has a high CPOE adoption rate. But it’s running into difficulties with another requirement – maintaining a problem list for more than 80 percent of all patients.

The Christ Hospital uses EHRs on both the hospital and the physician ambulatory practice sides. The ambulatory group has traditionally used problem lists, while inpatient physicians have not embraced the concept — it’s situations like this where the inconsistency of this physician documentation requirement poses a problem. “That was something we didn’t really push in 2008 when we initially went live,” says Alex Vaillancourt, the hospital’s vice president and CIO.
To establish regular use of problem lists, the hospital simply asked its physicians to use the feature. The conversations have helped, says Vaillancourt; doctors weren’t resistant to using problem lists — oftentimes they just forgot they were there.

Phoenix Children’s Hospital is also looking to address some components of physician documentation, as well as a few additional modules procured from the vendor for quality measures. “Even though we can extract data from an EMR and submit it, it has to be through the certified EHR,” says Vaidya.

Other facilities are working to ensure a smooth transition to an EHR system. Iowa Health System, the state’s largest integrated health system, is currently in the process of implementing a new EHR. Before settling on a vendor (Epic Systems), it interviewed about 600 physicians and staff members across its facilities. The move towards EHRs is a change in physician workflow, and like any change, can be disruptive. “We wanted to make sure that the disruption [was offset by] value,” says Joy Grosser, the health system’s CIO.

In terms of meaningful use, Grosser cites the health information exchange as one of the biggest challenges. “One of the stumbling blocks is trying to get to that point where health information exchange is routine, so we’re able to share information across settings,” she says.




Iowa Health System is focusing on adoption and striving to demonstrate the benefits of the electronic system to every user who comes across it. “IT doesn’t care for patients. We’re just trying to support people who do,” says Grosser.

Staying up-to-date
Although meaningful use has been creating a buzz in the medical community for months, keeping up with the changes in regulations, as well as products and services that are flooding the market, can be overwhelming.

Smaller providers find it especially hard to stay on top of all the HIT requirements. “Many small facilities absolutely do not have the resources to dedicate someone to full-time monitor meaningful use,” says Cheyenne Thomas, manager of regional accounts with Information Resource Management, a division of Spokane, Wash.-based Inland Northwest Health Services. IRM manages a health IT network with more than 4,000 physicians in 34 hospitals and health facilities throughout western U.S.

Facilities that lack meaningful use leaders often think investing in certified software is good enough. “That’s the easy part,” says Marc Johnston, director of regional accounts with IRM. “The tough part is going to be proper data capture within the facility, the process and the procedure [of implementation].”

Johnston says a common mistake among facilities is duplication of data, which won’t fly for meaningful use recording. In many instances, it’s an honest mistake. “It really comes down to the lack of understanding, knowledge and education about meaningful use and what providers truly need to do in their facilities,” he says.

Larger facilities also say the amount of information can be overwhelming and emphasize the importance of appointing a leader or group dedicated to meaningful use. Iowa Health System has a functional team across its enterprise, including executives and subject matter experts. Similarly, The Christ Hospital established a Meaningful Use Steering Committee, which includes clinical, financial and executive hospital representatives.

This month, one of the committee’s initiatives is to organize an educational session on meaningful use for the physicians. Many doctors haven’t seen a complete list of measures required for meaningful use, while others didn’t even know meaningful use impacts the hospital. “The feedback we’ve had is that [information] has been fragmented enough that doctors don’t have a good handle on what the expectations are at all,” says Vaillancourt.

IRM’s Thomas echoes the notion of plentiful yet deficient information on the topic — on the daily basis, she gets as many as 20 invitations to webinars or events, all promising to explain meaningful use. However, she recommends declining such invitations. “My biggest piece of advice to anyone out there that’s working on meaningful use is to remember that CMS and ONC are your only official spots to get information about the meaningful use program,” she says.

Getting there
Meaningful use experts can offer advice to facilities paving their way to compliance. First thing’s first: get familiar with the objectives and the measures that are required to demonstrate meaningful use. Then, come up with “a plan of attack” and run a gap analysis, figuring out current compliance percentages and areas where additional resources, training or products are needed, advises Thomas.

Stimulus dollars are only available for EHRs that are certified by an authorized testing and certifying body. Facilities need to make sure to not only get their main piece of software certified, but also that the connections and data moved between different systems meet the standards the ONC put in place, says IRM’s Johnston.

Hospitals should choose a company with a long term track record of success that provides a broad portfolio of products that will be able to support the hospital in stages two and three of meaningful use. HIMSS offers an Online Buyer’s Guide, which Boone likens to a “HIT yellow pages.” The public, searchable database enables providers to search health IT products by specific product lines and categories.

Once the software is in place, adoption must take center stage, an effort made easier if the IT-side partners with a strong clinical advocate. “With an IT champion, you run into the same problem that IT has always run into in health care — how to make your technology investment pertinent to the business, pertinent to patient care and not just put in technology because it’s cool,” says Phoenix Children’s Sarnecki.

Collaboration between the IT and clinical realms should be supported by executive leadership in the organization and driven top-down from the CEO, as widespread employee adoption is critical. “I see a lot of implementations fall through or fail because of [the lack of] key stakeholder commitment to it,” says Siemens’ Castillo.

Experts offer a further word of caution. Phoenix Children’s Vaidya warns against hastily deploying EHRs to take advantage of the first wave of the available stimulus money. “There’s a lot of good literature on unintended and negative consequences of IT implementations that have been done too fast or have been done too early,” he says. “The real reason for meaningful use is to improve quality but if you’re somehow blinded with the rush to meet those requirements and reap the incentive dollars, you shouldn’t do it faster than you can begin [correctly].”

HIT moves ahead
Just four days after CMS and ONC opened registration to eligible professionals and hospitals, about 4,000 providers signed up for the incentive program, according to CMS. And in January, discussions also began about stage two measures. The transformation of the nation’s health care system through IT is well underway.

To facilities that are just starting the journey to EHRs, CIOs offer a piece of advice — don’t wait a minute longer. For those who don’t keep up, snips to Medicare reimbursements are in store, and rumor has it private payers are soon to follow suit.

Investing in IT infrastructure and changing the workflows of almost every hospital employee is a major culture change but CIOs encourage viewing ARRA as an unprecedented opportunity to transform the delivery of care.

Phoenix Children’s Sarnecki says ARRA runs the risk of sharing the same fate as the Health Insurance Portability and Accountability Act: it can be perceived as nothing more than a regulatory requirement with money behind it. “I think somehow you have to make ARRA important to the hospital for the mission of a hospital and not just important for the regulatory compliance or dollars,” he says.

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DOTmed Registered EHR/EMR Sales & Service Companies
Names in boldface are Premium Listings.

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Troy Lair, The Compliance Doctor, LLC, CA
DOTmed Certified
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International
Debora Smith, McKesson Corporation, BC, Canada

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