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March 15, 2010

Heavy Load — The Burden of Meaningful Use
By Alice Shepherd
For The Record
Vol. 22 No. 5 P. 20

Workflow changes and reporting requirements are just two of the issues providers must confront on the path to incentive-hood.

The HITECH Act of the American Recovery and Reinvestment Act (ARRA) allocates more than $17 billion in the form of Medicare and Medicaid incentives to accelerate EHR adoption. Beginning in 2011, hospitals, eligible professionals (EPs; ie, non–hospital-based physicians), and critical access hospitals may receive funding to adopt, implement, or upgrade certified EHR technology—provided they can demonstrate meaningful use of the technology. On December 30, 2009, the Centers for Medicare & Medicaid Services (CMS) released the proposed rule that defines meaningful use, lists criteria for demonstrating meaningful use, and describes the calculation of incentive payments, as well as penalties for failing to meet meaningful use criteria.

The CMS’ definition of meaningful use is divided into three stages. Stage 1, which begins in 2011, includes 23 objectives and measures for eligible hospitals and 25 objectives and measures for EPs that must be met. Details of stages 2 and 3, which will phase in more robust criteria, are still being worked out. Hospitals and physicians that want to collect incentives in 2011 need to demonstrate meaningful use according to stage 1 criteria by July 1, 2011, and October 1, 2011, respectively.

What Data Must Be Collected?
Stage 1 meaningful use criteria expect hospitals and EPs to electronically capture health information in a coded format, use the information to track key clinical conditions and communicate the information to coordinate care, implement clinical decision-support tools, and report clinical quality measures and public health information.

The following is just a small sample of what’s required:

• Eligible hospitals use computerized physician order entry (CPOE) for at least 10% of all orders; EPs use it for at least 80% of all orders.

• Apply clinical decision support at the point of care. Generate lists of patients who need care and use them to reach out to patients. Maintain an up-to-date problem list of current and active diagnoses. At least 80% of all patients seen by the EP or admitted to the hospital have at least one entry or an indication of “none” recorded as structured data.

• Report information for quality improvement and public reporting. Transmit at least 75% of all permissible prescriptions written by the EP electronically using certified EHR technology. Maintain active medication and medication allergy lists. In each case, at least 80% of all patients seen by the EP or admitted to the hospital have at least one entry (or an indication of none if the patient is not currently prescribed any medication or has no medication allergies) as structured data.

• Record and chart changes in vital signs. For at least 80% of all patients aged 2 and older seen by the EP or admitted to the hospital, record blood pressure and body mass index. Additionally, plot growth chart for children aged 2 to 20.

• Record smoking status for at least 80% of all patients aged 13 and older.

• Incorporate clinical lab test results into the EHR as structured data. At least 50% of all clinical lab tests ordered with results in a positive/negative or numerical format are incorporated in certified EHR technology as structured data.

• Send preventive/follow-up care reminders to at least 50% of patients aged 50 and older.

• Implement five clinical decision-support rules relevant to the clinical quality metrics for which the EP or hospital is responsible.

• Provide clinical summaries for at least 80% of all office visits.

• Exchange meaningful clinical information among the professional healthcare team. Perform at least one test of the certified EHR technology’s capacity to electronically exchange key clinical information.

• Conduct or review a security risk analysis and implement security updates as necessary.

“The government has purposely set the goal high to ensure its investment in healthcare IT will improve care, not just help hospitals install computers and software,” says Scott Weingarten, MD, MPH, CEO and president of Zynx Health Inc, a company providing evidence- and experience-based clinical decision-support solutions. “If meaningful use criteria are met, the probability of benefit to patients, and therefore all Americans, should rise significantly. CMS’ final criteria will probably change little from what was published on December 30. For hospitals that have not yet started on the journey of healthcare IT, it’s an aggressive timeline.”

“The industry has been sitting on the sidelines for the past year, waiting for the criteria to come out,” says James K. Lassetter, MD, chairman and CEO of Medicity, a health information exchange vendor. “Now, little time remains to upgrade technology and make workflow changes. Hospitals are in the process of digesting the requirements and wondering how to create reliable reports to demonstrate meaningful use. As you drive legacy enterprises to make changes, some pushback can be expected. For example, the fact that hospital-employed physicians are not eligible under the proposed rule to receive incentives caught some people off-guard. Physician practices, on the other hand, are uncomfortable because while they may qualify for stimulus funding, they are not going to be eligible for the 2% bonus currently available under the quality reporting initiative. And hospitals are challenged by the fact that only nine of the 35 proposed measurements of meaningful use are currently used for the Medicare pay-for-reporting program. That means a big expansion in reporting requirements.”

The Paper Chase
Of particular concern for providers are criteria requiring them to determine both the numerator and the denominator of a measure. Take, for instance, the requirement that hospitals use CPOE in the inpatient setting for at least 10% of all orders and EPs for at least 80% of all orders. Lassetter explains the challenge: “In order to demonstrate that 10% of orders were entered using CPOE, hospitals need to measure how many orders were entered manually using paper. The problem with paper is that it’s inherently difficult to measure. So in order to derive the denominator, they have to analyze all their paper transactions. The requirement to measure paper processes and creating an audit-proof report is viewed as an unexpected burden of the requirements.”

David Muntz, senior vice president and chief information officer (CIO) of Baylor Health Care System who also chairs the College of Healthcare Information Management Executives’ (CHIME) Advocacy Leadership Team and sits on its board of trustees, agrees. “The new rules are quite aggressive for organizations that are not fully electronic in that they require the measurement of processes which are still manual,” he notes. “Organizations that have not fully automated physician order entry, for example, will need to track how many manual orders they are processing to know whether they are meeting or exceeding the required percentages.”

Where to Begin? Who’s Responsible?
In addition to possibly upgrading clinical information systems to certified EHRs, hospitals and EPs will need to make workflow changes to gather and report meaningful use data. “Download the meaningful use criteria and become familiar with them. Then establish a meaningful use task force or committee that monitors progress against the criteria,” says Weingarten. “A handy tool is a simple checklist or spreadsheet that lists the criteria, their timelines, and the parties responsible for capturing the data. Some of the items on the list will be information that is already being collected for other purposes, so it’s just a matter of plugging the gaps. Then develop a project plan to make sure the criteria are met in a reasonable time frame.”

Leadership positions will bear much of the burden, says Lassetter. “The responsibility for reporting meaningful use lies with the CIO and CMIO [chief medical informatics officer],” he says. “They need to work together to implement the technology, the workflow changes, and the adoption strategy to achieve meaningful use, and they will have to measure the results.”

Staff leaders on the ground level play a key role as well. “CIOs will have to interpret the elements that are going to impact the organization, but the true executive sponsors will need to come from operations because the regulations require a fundamental change in the way we conduct business,” Muntz says. “While the technological requirements are relatively straightforward, it’s the workflow changes and their impact that cause me the greatest concern. I’m not sure there is adequate time for a large, complex organization or even a small, relatively simple organization to absorb all of the changes that are necessary to accomplish the overall objectives. It will require a very pragmatic and realistic approach.”

The project plan should follow a similar course to any significant clinical transformation process or IT implementation, including representation from the various departments, responsible parties, steering committees, and project teams. At Baylor, an executive steering team is forming with the chief operating officer as executive champion. Tentatively, the other team members include the CIO, chief medical officer, CMIO, chief quality officer, chief safety officer, chief nursing officer, chief financial officer, chief marketer, and an advocacy person. “The executive steering team sets strategy and policy and makes sure we stay on timelines and within budget,” says Muntz. “They will probably make about 10% of the decisions. We’re also going to engage the board. They need to know the implications because the effort will likely affect our capital consumption, as well as other initiatives already under way. In addition to the executive steering team, we will have a project steering team and several work groups. We intend to follow our existing governance processes.”

Membership on the project steering team has yet to be determined. “These are the people who will do the actual work,” says Muntz. “They need sufficient understanding to make decisions and enough authority to see that they get done. They will probably make 20% of the decisions, work groups about 70%.”

Baylor will expand the responsibilities of its Institute for Healthcare Research and Improvement, headed by the chief quality officer, to report on meaningful use data. “The stimulus package has not radically changed what we’re going to do,” says Muntz. “It has more of an impact on when we’re going to do things. Most CIOs are not stunned by what we have to do. While some of the reporting requirements are more onerous than anticipated, none are very far from the activities we had already planned on our journey to the electronic health record.”

There are staffing concerns, though. Some organizations already have the internal expertise to interpret the criteria and develop a plan. Others may bring in consulting firms, and some will need to hire additional employees. “A number of analyses have shown that there is likely to be a workforce shortage related to high tech and healthcare information technology,” says Weingarten. “Hospitals, health systems, and physician organizations may not have sufficient numbers of staff trained to perform these functions. Forward-thinking organizations are now beginning to recruit and retain individuals with the needed expertise.”

For example, Baylor is considering hiring a new full-time employee to coordinate the efforts to achieve meaningful use. “We’ll need someone with quality reporting experience who is also an extraordinary project manager,” says Muntz. “Workflow changes will impact almost every stakeholder involved in patient care, and the new staff member will be the champion that gets others to examine their existing activities and work to optimize those.”

As organizations progress on their journey toward electronic records, data collection and reporting will eventually be automated and become much less difficult. In 2011, all results for all objectives, including clinical quality measures, will be reported by EPs and hospitals to the CMS, while Medicaid EPs and hospitals will report to the states through attestation. “Meanwhile, organizations will be applying to become certifying bodies for CMS,” says Weingarten. “They will accredit or certify that meaningful use has been reached.”

In 2012, the CMS has proposed requiring the direct submission of clinical quality measures to the CMS (or to the states for Medicaid EPs and hospitals) through certified EHR technology.

Key Policy Goal: Exchange of Structured Information
The CMS is aware that the infrastructure to support the electronic exchange of structured information is not yet available in many parts of the country. For this reason, it has excluded the exchange of structured information from many stage 1 criteria or set relatively low performance thresholds for measures that do rely on the electronic exchange of structured data. The threshold will be raised for stage 2 and 3 criteria as the capabilities of HIT infrastructure increase. The intent and policy goal of raising the thresholds is to encourage patient-centric, interoperable health information exchange across provider organizations.

— Alice Shepherd is a southern California-based business-to-business journalist specializing in healthcare topics.


A New Form of Cloud Computing
Complementing the proposed rule defining meaningful use, the Office of the National Coordinator of Health Information Technology (ONCHIT) has issued an interim final rule that specifies the adoption of an initial set of standards, implementation specifications, and certification criteria for EHRs. The ONCHIT will also issue certification criteria and processes to guide EHR vendors in configuring their systems.

“Many EHR vendors are proposing a cloud-computing delivery model to help providers become compliant with meaningful use criteria,” says James K. Lassetter, MD, chairman and CEO of Medicity, a health information exchange vendor. “Organizations should be aware that cloud computing has a serious limitation in that none of the applications will be available if Internet access is disrupted for whatever reason. It’s not acceptable that providers have to close their doors, delay seeing patients, or use paper and then have to integrate the information back into the system.”

Lassetter recommends a new hybrid application, called client-cloud, that does not require an Internet dial tone to support continuity of work because it includes “client” components that are resident on local computers. “If Internet access is cut, physicians can still view lab reports even though they will be the results as of the last sync with the cloud,” he says. “When Internet access resumes, the new lab results are downloaded and orders written while the physician was disconnected are uploaded. Client-cloud is a more suitable architecture for healthcare because providers can keep computing even when their Internet connection is interrupted.”

— AS