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Outside Track Advances

March 28, 2010
by Mark Hagland
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Think smaller and rural hospitals are hopelessly behind in satisfying the meaningful-use criteria under ARRA-HITECH? Don't be so sure
Fred Evans
Fred Evans

Much electronic ink has been spilled of late bemoaning the difficult straits of many types of hospitals as the ARRA-HITECH legislation's provisions play out in the healthcare IT industry. Certainly, the requirements involved in hospitals' being able to attest to meaningful use in time to receive the 2011 funding are rigorous and highly challenging. And if CIOs at any type of hospital might be assumed to be worried about meeting those requirements, it would be leaders at the nation's smallest and most rural hospitals (as distinct from hospitals applying for HITECH funding through the Medicaid program, which face an entirely separate set of requirements). But CIOs at many of these hospitals are expressing what might seem like surprising confidence in their progress to date, and are moving forward believing they can do what's needed, in time to receive the first distribution of federal funding in 2011.

Take, for example, Fred Evans, CIO of the 88-bed Hill Country Memorial Health System, an 88-bed hospital in Fredericksburg, in the Hill Country of central Texas. That hospital's board had committed to a vendor in 2004, and hired an interim CIO who brought the system live in October 2005, three months before Evans had joined the staff. After implementing pharmacy, lab and radiology in the initial go-live, Evans helped the hospital go live with nursing documentation in 2007 and with computerized physician order entry (CPOE) and physician documentation in 2008; and with an electronic medication administration record (eMAR) in July of last year.

Still, there have been setbacks. Both nursing documentation and CPOE went live before clinicians were fully ready for those elements, Evans, reports. As a result, nursing documentation was reworked, and went live a second time about a year ago, while CPOE went live for a second time just as this issue was going to press. Evans and his colleagues are also waiting to upgrade to the latest version of their vendor's core EMR product. But they are also persevering and moving forward, requiring all physicians to become proficient in CPOE, and expecting within a couple of months to be totally paperless in clinical operations.

“We fully expect to meet these criteria” under meaningful use, Evans says emphatically, even as he concedes that he and his colleagues have yet to crack the code on meeting the meaningful use requirements for the reporting of quality and outcomes data, particularly the public health reporting requirements. “My biggest uncertainty,” he says, is the “data exchange requirements. I believe we'll be fine with the CPOE requirements by the end of this year.”

Meanwhile, in the small town of Sanford, about 40 miles south of Portland, Maine, Charlie Caruso, CIO and vice president, business process improvement, believes that his organization, the 53-bed Goodall Hospital, will do well in terms of ARRA-HITECH funding, even though he and his colleagues have made the conscious decision not to implement CPOE until the summer of 2011, therefore foregoing the first round of federal funding. “We've purchased CPOE” from their vendor, Caruso says, “but we've had to delay the implementation of both CPOE and eMAR, along with bedside medication verification, because of financial constraints related to the recession; and then our vendor pushed out our start dates.” Nevertheless, Caruso says there might be another way in which he can achieve the CPOE implementation needed to obtain the 2011 funding, if he bypasses his vendor and partially implements CPOE using the hospitalists caring for patients in his hospital. There are in fact a number of gray zones around what “10 percent of orders” actually means, he points out.

Charlie Caruso
Charlie Caruso

Unrealistic or intrepid?

Some industry experts are skeptical that such confidence will be borne out by success in 2011, among them, Jane Metzger, principal researcher in the Waltham, Mass.-based Emerging Practices division of the Falls Church, Va.-based CSC.

“The more you delay in the first stage, the harder it will be to get everything done in time.”

Brian Moreau
Brian Moreau

“I think the single biggest challenge boils down to the issue of having so much to do in so little time,” says Metzger. “And even though the new rules decoupled the stages from years, it just means there's a little more room for play in the first part of the meaningful use cycle; but the more you delay in the first stage, the harder it will be to get everything done in time.” The implications for smaller hospitals with fewer resources are immense, Metzger says. “For any hospital that has a fairly good volume of Medicare patients, the penalties can be even higher than the incentives. And so getting things done in time, aside from reputational elements, also has financial implications. And while the influence of Medicare is capped on the incentive side, it's not on the disincentive side.” As a result, she says, CIOs and other hospital executives at smaller hospitals are going to have to very, very carefully assess the financial tradeoffs, given, she notes, that, “Because the incentive is after the fact, where do you get the resources you need upfront?”