Across the U.S., health care providers are scrambling to meet the 2012 deadline for the first stage of meaningful use and thereby qualify for hefty reimbursement payments. If met, payouts could be as high as $64,000 for physicians and $2 million or more for hospitals over a six year period.
A recent survey conducted by the Healthcare Information and Management Systems Society (HIMSS) indicates that 44% of hospitals say they are likely to meet stage one requirements for meaningful use. But, for many providers, achieving any level of meaningful use is a daunting IT challenge. Transitioning to electronic records is a massive change for those doctors who have relied on manual, paper-based systems. At the same time, there’s a great deal of confusion surrounding the rules and the best strategy to align staff, resources and internal processes to capture data and develop necessary workflow systems.
As we approach mid-year, there are widespread differences in providers’ level of readiness, and Accenture estimates that roughly half of US hospitals are at risk of incurring penalties when enforcement begins in 2015. These penalties will come in the form of decreased Medicare repayments – something most providers simply can’t afford.
To better understand the issues the industry faces in meeting the requirements of meaningful use, I spoke with J. Scott Joslyn, PharmD, Senior Vice-President and CIO of MemorialCare Health System. Joslyn is a member of the HIMSS Analytics EMR Stage Level 7 Adoption Model Advisory Council, making him one of a handful of experts who visits providers and hospital networks to assess their Level 7 achievement and advise on implementation and relevance to Meaningful Use. Moreover, MemorialCare Health System is also one of the few provider organizations to be just steps away from reaching Level 7 this year.
What is your role on the HIMSS Analytics EMR Stage Level 7 Adoption Model Advisory Council?
I really have two roles with HIMSS Analytics as it concerns Stage 7 and the Adoption Model Advisory Council. The first is to periodically review the criteria for qualification at each stage. While they have remained principally the same over time, the capabilities of an organization that one would expect to see at each stage have evolved with the advancement of technology and the experience gained in using it. The intent is to keep the Stage 7 process alive, meaningful, and relevant to what we ought to be doing with EMRs, much of which was later reflected in the approved and proposed elements of Meaningful Use. Stage 7 will continue to “push the envelope” with respect to applied HIT.
The second role is as a “surveyor” on small teams that visit hospitals to assess their achievement of the EMR Stage Level 7 criteria. It’s usually a day-long visit where each criterion is reviewed in detail.
In your view, how ready is the industry to meet the meaningful use criteria?
I would guess that perhaps half of those organizations who have said they can or will meet Stage 1 requirements will do so in the first year. Perhaps a greater number can but I believe many will be more strategic in attesting and likely attest in federal fiscal 2012. That provides more time to develop a cushion in maintaining a comfortable margin above the 80% threshold items, e.g., problem list.
Such a strategy stems from the fact that you must only achieve meaningful use for a consecutive 90-day period in your first year of attestation. Given that we are in the latter half of federal fiscal 2011, the “time off” to solidify organizational approaches to some of the more challenging criteria before the second year begins for anyone attesting in FY 2011 is much shorter than it would be if, for example, someone attests after the first quarter of 2012. Yes, that would mean a slight delay in the receipt of funds. But once you attest in the Medicare program, you begin a forced, four-year march of attestation for which you cannot simply take a year off without losing significant incentive dollars. I think many will consider that in their attestation plans. That said, I think a fair number of organizations are on the verge of MU attestation, if not in position to attest today, especially those which were early in their EMR rollouts.
What is the biggest challenge providers face when trying to meet meaningful use requirements?
I would say that a big challenge in Stage 1 is being absolutely clear as to what is required for any given meaningful use criterion, and then to be sure who in an organization has the ultimate accountability to achieve and maintain that criterion. The process also is new for everyone, so there is a start-up effort within the enterprise to engender support for meaningful use achievement and to coordinate efforts.
Also, for many organizations, large portions of the physician staff are independent of the hospital and must voluntarily commit to CPOE, for example. In later stages, I think challenges will arise in the breadth and depth of requirements – all good things to do for the sake of patient care and overall quality-- but many of them new in terms of specificity and form. The stages as they are envisioned now represent huge process changes over a relatively short period of time. If you consider the cultural implications of EMR rollouts along with proposed latter-stage meaningful use requirements, achievement of meaningful use by a majority of organizations may go well beyond 2016.
What has the path to adoption been like for your organization?
We have not seen any systematic resistance in our organization on the inpatient side. We have been going down this road since 2004 with our current EHR application and since 1991 with its predecessor system which itself garnered some significant physician adoption. So, we are well beyond debates about the effect of an enterprise wide EHR adoption strategy and the various components and EHR functions found in the MU criteria.
There are some major challenges on the ambulatory side, however, related to the reimbursement mechanisms (physicians who do not see significant Medicare or Medicaid populations are not eligible to receive noteworthy incentives) and the fact that the criteria chosen are heavily biased toward primary care practices, leaving some of our specialty physicians with significant hurdles.
What is the most common misperception about what it takes to achieve meaningful use?
I have not seen this first hand, but I gather from what I have read and heard that there are organizations which intend to buy, implement, and use an EMR in a meaningful way in a very short period. To be sure, there is a lot more “shelfware” available with any given EMR since we started our EMR project. That is, there are prebuilt configurations that have been time-proven to work in most situations and which can be reasonably tailored in shorter periods of time than it took us. However, our experience suggests that the time associated with change management, culture, and leadership aspects of EMR rollouts is largely incompressible. My worry would be that some efforts may fall short of achieving Meaningful Use or receipt of any incentives, or might fail altogether. I personally believe Meaningful Use is an appropriate set of objectives while incentives are very much secondary and should not be pursued at the expense of a careful EMR rollout and adoption plan.
Which section(s) of meaningful use are the most ambiguous and how can these be made clearer for providers?
The clinical quality reports are a major challenge. Dealing with the large number of inclusion and exclusion criteria, many requiring data that are not “traditionally” collected in machine readable (structured) formats, is a major source of current activity. Meeting actual quality “goals,” which are not yet present in the regulations but sure to come, is likely to significantly increase this effort going forward.
Several of the patient engagement core criteria such as keeping electronic copies of the patient record and/or discharge instructions, are not terribly well characterized. This has led to a lot of work on our part, as it has at other organizations I am sure, to understand what compliance means in terms of workflows and documentation. In conjunction with the menu criterion for creation of summary of care documents at transitions of care, there appears to be some duplication of effort that could have been avoided.
What are some of the commonalities among organizations that have reached Stage 7?
Organizations that have gotten as far as potentially qualifying for Stage 7 are pretty thoughtful, deliberate, and sensitive to cultural and change management issues associated with technology. They know their organizations well and how to exploit the technology they have in place. The margins of qualification that have arisen in my experience are in the remaining vestiges of paper. There is an unavoidable flow of paper from outside the organization, for example, which needs to be part of the medical record. Also, there are consents and there are “codes” where use of paper as opposed to the EMR is simply faster and better patient care. Often the advice is then around ideas to eliminate paper if safety or efficiency can be improved.
There are also discussions about sustainability with respect to Stage 7. Stage 7 organizations don’t generally consider themselves “done.” They tend to be learning organizations with formal processes of continuous improvement, LEAN for example. Wherever they may be in their thinking here, we strongly encourage them to press ahead with their efforts and, frankly, help us in shaping the direction of the program as their learning suggests.
Aside from EHRs, are there other priority technologies providers should consider in the next year as part of a comprehensive and long-term meaningful use strategy?
Even before the emergence of HITECH, ARRA, and most recently Accountable Care Organizations (ACOs), there has been growing recognition of the need to coordinate care beyond the “four walls” of any given institution. That is, except for the few highly integrated healthcare organizations, we are all part of a “system of care” when viewed from the patient’s perspective. We see two areas of need that are either explicit or implied in Meaningful Use, health information exchange (HIE) and population management. The HIE space is a somewhat confusing place and in a state of flux. It is far less about technology that largely exists to address the issues, and much more about policy, regulation, collaboration, and patient privacy. There are opposing forces of information liquidity, fluid exchange, information granularity, privacy, and patient control. These simply aren’t sorted out. And, on the one hand, meaningful use necessitates robust exchange while, at the same time, little is being done by federal and state governments to create a “receptive” environment under which providers feel they are “safe” to exchange data on behalf of their patients without fear of treading on one regulation or another.
In the area of population management, it is clear we need beyond HIE the ability to understand two things: 1) the collection of data that pertains to populations of patients with given problems; and, 2) individual patients with collections of information about their health over time. As we see it, there is a need for an “über warehouse” that transcends an organization and serves otherwise independent partners in pursuit of ACO capabilities and who will ultimately and collectively be at risk for overall care delivery. There are tools that we see in the market to address these needs and which complement our EMR. At the moment, it is a matter of fully understanding our requirements, and establishing and governing the collaboration mechanisms or “clinical integration” processes among provider, payer, and other imagined partners.
How long has your organization, MemorialCare, been preparing for meaningful use?
To the extent that meaningful use corresponds to many of the objectives we had in mind when we originally purchased an EMR, we have been preparing in earnest since 2004. However, considering that we had about 30% CPOE with a system we installed in 1991, we have sought some meaningful use objectives for a much longer period. What meaningful use did for us is to refine and in some cases extend or accelerate our EMR objectives. To some degree, we had all of the 14 required meaningful use criteria in our EMR rollout plan. We had not considered or prioritized some of the “menu” items of Stage 1, however. Thus, meaningful use has helped to shape and prioritize our EMR objectives.
What stage has your organization met thus far? Can you tell us a little about the process?
We have achieved meaningful use Stage 1 with three exceptions that have been nearly overcome. These are the problem list and reporting quality measures on the required list, and the capability to submit electronic data to immunization registries. In the latter case, it has more to do with someone being able to receive our communications as opposed to our ability to send information. The quality measures are simply hard, for us anyway, mainly related to the intense granularity of the population inclusion and exclusion criteria in the final rule.
Meeting the problem list adoption criterion is really a matter of our policies. Physicians “own” the problem list in our organization because it is fundamental to driving downstream care quality processes. It is not information we expect a nurse or other caregiver to provide though they may be quite cognizant of a given patient’s medical “problem(s).” We are now at or near 80% in most of our facilities where we have used our system’s alerting capabilities to remind physicians of this important function which, as noted, is far less about meaningful use than it is about our care processes and the uses we intend to facilitate with a careful, complete problem list.
As to process, we created a meaningful use steering committee chaired by our CMIO with subgroups devoted to various aspects of meaningful use. We have coupled these activities with campus committees devoted to physician and clinical informatics that are chaired by practicing physician champions who have been involved with our EMR rollout since its inception.
What does MemorialCare and other organizations still need to do to reach stage 7?
The key element we are missing is closed loop medication management. When digesting and thinking about To Err is Human and the subsequent Crossing the Chasm from the Institute of Medicine in the period after Y2K, we settled on an approach to begin with an integrated core clinical system and work our way to the bedside with patient safety improvements. Thus, we pursued a comprehensive EMR strategy and left closed loop for another day. For us, we felt that pursuing both strategies simultaneously would risk success and exceed our ability to manage change across such a broad set of objectives.
With a solid EMR activation in place, we are now turning our attention to closed loop medication management, but as part of a comprehensive effort that includes IV pump formulary management, supply chain considerations, and drug packaging systems for a multi-hospital enterprise. We look forward to flying the Stage 7 “flag” but we will first adhere to a fairly rigid plan that fully considers our requirements and the needs of key stakeholders.
MemorialCare’s success in implementing meaningful use and Scott’s experience advising other providers on the steps needed to do the same provide valuable insight into an industry in transition. The digitization of health records is an important first step as providers increasingly embrace technology to improve the care and health outcomes of patients and reduce rising medical costs. Microsoft and its partners are working with provider organizations across the country to not only implement EHRs, but to effectively link existing systems to improve communication and coordination of care across the health ecosystem.
Do you have questions for Scott about how your organization should be thinking about or implementing strategies and technologies to achieve stage 1 of meaningful use? If so, please leave a comment here and Scott will try to answer them asap.