By Gabriel Perna
If you put the industry’s best-known thought leaders in the same room, they might not agree on much.
They might differ on whether or not the attestation timeline should be extended or even be delayed for Stage 2 meaningful use of electronic health records (EHRs) under the Health Information Technology for Economic and Clinical Health (HITECH) Act. They might differ on whether the transition to the ICD-10 code-set can be done by October 2014. They might even differ on the color of the wall.
But there is one thing that everyone would agree on, and it doesn’t matter if it’s the CIO of a big-time health system in an urban area, an outside consultant, or someone who works in a smaller, rural setting. They would all agree that CIOs are dealing with a serious number of policy issues coming down the pipeline, all of which have overloaded their already crowded plates.
Healthcare Informatics Associate Editor Gabriel Perna recently spoke with seven industry insiders and leaders, many of whom testified on meaningful use in front of the Senate Finance Committee in Washington. These leaders—a cross-section of CIOs and policy experts—talked about everything from the impact of a possible Stage 2 altered timeline to compliance with security provisions of the Health Insurance Portability and Accountability Act (HIPAA) and payment model reform under the Affordable Care Act (ACA).
Implementing the IT that complies with and supports these broad policy mandates, while dealing with day-to-day responsibilities, is the reality at provider locations across America. During the course of these interviews, thought leaders unfurled the challenges that surround each measure and looked to answer that pervasive question: which one should come first?
In the past few months, there have been ongoing, industry-wide discussions about Stage 2 of meaningful use. The initial wave of noise began in May when the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) sent out a proposal for a one-year extension of Stage 2. CHIME CEO, Russell Branzell, offers that this policy change is not an unreasonable request to make of the Office of the National Coordinator for the Health IT (ONC) and the Centers for Medicare and Medicaid Services (CMS).
“Our argument to the ONC and CMS…is we’re not asking for huge leniency or a break. We’re saying make the timing reasonable, give some time to the people who are actually using this to settle in and get some benefits from it. We want the program to be successful. We think the investment in HIT is dead on target. What’s occurred, though, is over time, we’ve gotten a little off track in putting this in and what we’re doing with it. It gives them [the government] and us a reasonable chance at success,” Branzell says.
This is especially the case with regard to Stage 2, Branzell says. While Stage 1 set the groundwork, the clinical quality measurements (CQMs) in Stage 2 will require significant resources, both from an IT and clinical standpoint, to be managed on a continual basis. In addition, he says, there is the issue of vendor readiness.
Both Branzell and George T. Hickman, executive vice president and CIO of Albany (N.Y.) Medical Center and CHIME’s board chair, say there are various reasons why vendors might not be ready for Stage 2 requirements. This includes, they say, technologies around transitions of care and patient portal integration.
“I don’t want to implement two portals, so I’m trying to integrate my portal implementation to two separate electronic health records. While I know some portal providers out there can do that, what’s been going on is that EHR vendors are bringing their preferred partner to the table and it may or may or may not be agnostic to your circumstance,” says Hickman, who cites as an example the Chicago-based Allscripts and its portal partner, Jardogs (which Allscripts acquired).
“For example, I need to integrate Jardogs with the Siemens EHR, and they haven’t done that before. And they haven’t done it with a bunch of others. And the same thing can be said about other like partnerships,” he says.
In rural Kentucky, Randy McCleese, vice president of Information Services and CIO at St. Claire Regional Medical Center, concurs with the sentiments of Branzell and Hickman. Like them, he says the timeline might be pushing vendors too fast and the government should give providers more time to attest.
“From what I’ve heard, and I don’t think this is specific to rural, there are quite a few organizations that are not ready to attest to Stage 2. Some of it is, they have so many things on their plates. I was talking to a CIO last week and they have moved other things into higher priority than Stage 2, because they don’t feel the payback is there,” McCleese says.
Discussions on Stage 2 are at a fever pitch, says CHIME’s director of public policy, Jeff Smith. “The awareness of the meaningful use policy is the highest I have ever seen on Capitol Hill,” he says. Anita Samarth, president of Clinovations, a Washington, D.C.-based consulting firm, is betting on some kind of delay or extension. However, most experts are unsure whether or not all the talks will amount to anything.
Healthcare Informatics has dug deeper into the thoughts of these industry leaders on these regulatory demands in HIT Voices, a three-part series. See what else Anita Samarth, Ed Marx, and George T. Hickman/Russ Branzell had to say on Meaningful Use, ICD-10, and other policy topics.
Also please feel free to vote in our poll on whether or not the Stage 2 timeline should be altered and weigh in at our LinkedIn Group
As CIOs weigh the decision of whether or not to attest to Stage 2, many are moving ahead full force on ICD-10, which will have to be implemented by Oct. 1, 2014 or providers will see an effect on their Medicare reimbursement. Boston-based Beth Israel Deaconess Medical Center CIO, John Halamka, M.D., goes as far as to say ICD-10 is a higher priority, along with HIPAA, than meaningful use.
“Ask yourself, ‘What are the things you cannot miss?’ If you delay a go-live of an application; your users may be frustrated. If you don’t get your compliance and regulatory mandates, you may go out of business. ICD-10, if you don’t do it on time, you can’t send bills out. If the Office of Civil Rights believes you aren’t safe guarding data, you get huge fines. It’s the regulatory and compliance mandates, specifically around ICD-10 and security, which are the top priorities,” Halamka remarks.
Branzell of CHIME says that many CIOs in advanced electronic environments who have already attested to Stage 1 are asking, “Why do Stage 2, considering the financial risk of ICD-10?”
At Texas Health Resources, senior vice president and CIO Ed Marx confides that his organization is moving forward with ICD-10 as if the Oct. 1, 2014 date isn’t going to change, even as some associations continue to ask for a delay (CMS officials have been clear in their intention not to delay the required transition date beyond Oct. 1). “We’re feeling pretty good with our vendor, with our internal HIM, that we’re going to make those dates,” says the industry veteran.
Other CIOs have similar mindsets. Randy McCleese at St. Claire Regional says his organization is preparing for the transition as if the date was cut in stone and it’s become one of their big focuses. Hickman says that at Albany Medical Center, ICD-10 testing will force the organization to put a freeze on plans to bring in new software by April or May of next year. He adds that even though the organization is on track to transition to ICD-10, a lot of work left remains.
“Many things that we do, don’t keep me up at night; this one does,” Hickman acknowledges. “There are so many moving parts to it, and so many interrelationships.”
The difficulties of this ICD-10 transition and the fact that most don’t see the compliance date being moved again have made it an inescapable reality for CIOs. HIPAA compliance, mentioned by Dr. Halamka, is another looming policy element that is top of mind for many CIOs. Texas Health’s Marx says the organization has “doubled down” on its security measures.
If it’s not meaningful use, ICD-10, or even HIPAA, then it’s payment model reform under the ACA, including the voluntary accountable care organization (ACO) program and the mandatory value-based purchasing program. For many organizations, like McCleese at St. Claire Regional Medical Center, ACO formation is a front-and-center issue.
This year, the center is joining with the Bon Secours Health System to form an ACO. To help with data reporting and analysis, St. Claire hired an analyst to focus on the ACO. The analyst told McCleese that he didn’t initially understand the extent of the ACO initiative.
“He said, ‘I had no idea it was anywhere near this big.’ I said, ‘Now you understand why I said you need to go out of your analyst role into this role to make sure we can get the data we need,’” recalls McCleese. “We as an organization, and I think I’m hearing this in the industry, this is the future of healthcare and the way we are going to get paid. So we want to make sure we get it right.”
While Marx’s Texas Health Resources pulled out of the CMS Pioneer ACO to avoid paying a penalty, he says the organization is focusing on it and pursuing other arrangements. Halamka says the focus on ACO creation is important because not only does it relate to Medicare reimbursement, but private insurers are moving from fee-for-service contracts to wellness, pay-for-performance measures.
It might not be that easy though, says Branzell. The clinical side of ACO formation, at-risk contracting, and other long-term efforts in this vein are often directly at odds in terms of resources and requirements with optimization on the current platform within the current payment system. “Those two are constantly butting heads,” he says.
What’s clear, if CIOs are able to agree on one thing, it’s the fact that each policy issue presents a set of specific challenges, which sometimes interfere. Which one should take the highest precedence? Well, that’s where the answers differ (see sidebar).
For John Halamka, M.D., there is something he advises every CIO to do every so often to counter the stresses and pressures of this ongoing reality. Shovel manure.
“I own a farm, so at the end of the day of complex policy and technology activities I can go shovel manure. My advice to every CIO is make sure you have whatever your equivalent is of shoveling manure,” he says.