EXECUTIVE SUMMARY:
While there is no shortcut to meaningful use, getting the fundamentals right is essential to smoothing the way to qualifying for incentives.
Though the Stage 1 attestation process for meaningful use (MU) incentives opened in April 2011, the number of hospitals that will attest in the early stages is likely to be underwhelming, according to at least two recent surveys. One, from the Ann Arbor, Mich.-based College of Health Information Management Executives (CHIME), found that fewer than one-third of responding healthcare CIOs expect to qualify by Sept. 30, 2011. A second, from the Chicago-based Healthcare Information and Management Systems Society (HIMSS), found that only 44 percent of hospitals thought they would be ready to qualify by May 2012.
That's disappointing, but not surprising. Understanding and meeting the MU requirements demands a significant effort. To qualify for incentives in Stage 1, “eligible hospitals” must meet 14 core measures, and then demonstrate they've also met five of the remaining 10 menu set measures. “Eligible professionals” (clinicians) must meet 15 core measures and five of 10 menu set measures. Ongoing clarifications from the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) have added to the challenge. One clarification, for example, requires that organizations “possess” the software for all of the menu items, even though they are only expected to “demonstrate” five of the 10 menu set measures.
MU ‘To Do’ List
Depending on where you are in your EHR implementation journey, this can be a several-month multidisciplinary effort that includes:
understanding the regulations and tracking the constant clarifications on an ongoing basis;
completing a “current state” analysis;
comparing “current state” to the desired “future state” as defined by the regulations and your own strategic goals;
completing a detailed data element mapping analysis to thoroughly identify the data requirements needed in the clinical workflow process (readers should make note of the intensity of data requirements within the clinical quality measures);
creating a plan to address the gap, including a detailed timeline, detailed technology requirements and specific clinical workflow changes;
executing the plan;
testing and validating that you've met the measure objectives (healthcare organizations can receive some guidance on this from a MU attestation calculator that CMS has published);
determining your 90-day measurement period for year one;
documenting your numerators and denominators for each measure requiring them;
identifying who from the organization will attest and when; and
completing the attestation online.
Despite such demands, we believe the number of organizations attesting is far lower than it should be. Having an electronic health record (EHR) in place that meets MU standards is quickly becoming a must-have for any clinical operation, so why not attain incentives to offset the costs? It can be done in a reasonable time period if hospitals and physician groups take some thoughtful initial steps.
ONE OF THE BIGGEST MISTAKES ORGANIZATIONS MAKE IS NOT FULLY UNDERSTANDING THE MU REQUIREMENTS, INCLUDING NOT TRACKING ALL THE UPDATES, CLARIFICATIONS, AND IMPLEMENTATION GUIDANCE THAT THE CMS AND ONC HAVE PUBLISHED ON THEIR WEBSITES.
CREATE A STRONG FOUNDATION
If you haven't done so already, an important first step is to model your financial opportunity in the MU EHR Incentive Program, based on your volume of Medicare and Medicaid patients. A simple approach is to use the instructions on the CMS Tip Sheets for Medicare and Medicaid to calculate your potential return. A clear, realistic picture can help you: first, understand the value proposition for your organization's MU project; second, engage in a more precise budgeting process; and third, confidently balance MU with other competing priorities.
That balance is critical. Like most hospitals and health systems, you're probably already contending with multiple strategic considerations that range from deciding whether to apply for the CMS Medicare Shared Savings Program to incorporating ICD-10 coding and weighing merger and acquisition opportunities. Those competing priorities could cause you to allocate inadequate resources for your MU project; the resulting hasty implementation might make short-term financial sense, but may not address key patient safety issues and could put your future EHR incentives (Stages 2 and 3) at risk.
In contrast, designating MU as a strategic project and placing it in the context of overall strategic planning can help ensure there are enough resources to plan, design, implement, and foster clinical adoption of a system that meets both the MU measures and your organization's needs.
An important next step is to create a dedicated program management structure with clearly defined roles and responsibilities-some exclusively for MU, others integrated into existing clinical structure-and to begin creating the project plan. One effective component of the plan is to engage your government affairs and compliance departments to take leadership roles in understanding the regulations, delivering the needed MU documentation, and tracking the updated guidance from ONC and CMS using the published FAQs.
In addition, the program management team should collaborate as much as possible with: your EHR vendor; other hospitals and health systems, especially those who use the same EHR vendor; consultants; and health information technology (HIT) organizations like the American Medical Informatics Association (AMIA), CHIME, and HIMSS. This enables your team to benchmark what's possible and avoid reinventing the wheel.
Finally, complement the program management structure with a strong communication plan that engages the entire organization and helps people understand what the MU program is and how it's tied to your existing strategic mission, vision, and goals. If your employees have a clear sense of MU's strategic, financial-and, especially, clinical and patient safety value-they are more likely to engage in the activities needed to achieve the incentives. Seeing the link will help eliminate concerns that the MU program is only about the incentive money and is out of context of the organization's strategic plan.
AN IMPORTANT FIRST STEP IS TO MODEL YOUR FINANCIAL OPPORTUNITY IN THE MU EHR INCENTIVE PROGRAM, BASED ON YOUR VOLUME OF MEDICARE AND MEDICAID PATIENTS.
Once these basic building blocks are in place, you can turn your attention to two near-term challenges for Stage 1 attestation: first, gauging and closing the gap needed to attain the incentives and, second, simultaneously assessing how you will work with existing or prospective EHR vendors.
GAUGE AND CLOSE THE GAP
Perhaps one of the biggest mistakes organizations make is in not fully understanding the MU requirements, including not tracking all the updates, clarifications, and implementation guidance that the CMS and ONC have published on their websites. The result is that many organizations lack clarity on the measures and underestimate what they need to do moving ahead.
One way to fully understand the MU requirements is to look at each objective measure across four dimensions, and then look at the multiple data points within each dimension. The four dimensions are:
Understand how to calculate “the numerator and denominator” for each objective. On its website, CMS explains this by dividing the calculation into two groups: “one where the denominator is based on unique patients seen or admitted during the EHR reporting period, regardless of whether their records are maintained using certified EHR technology; and one where the objective is not relevant to all patients either due to limitations (e.g., recording tobacco use for all patients 13 and older) or because the action related to the objective is not relevant (e.g., transmitting prescriptions electronically and for whom the denominator is based on actions related to patients whose records are maintained using certified EHR technology.)” Some objectives do not require a numerator and denominator, but are “Yes/No” or “perform one test” measures.
Meet the objective using certified EHR software with a process acceptable to CMS. According to CMS, “In most cases, an eligible professional or eligible hospital is not limited to demonstrating meaningful use to the exact way in which the Complete EHR or EHR Module was tested and certified. As long as an eligible professional or eligible hospital uses the certified Complete EHR or certified EHR Module's capabilities and, where applicable, the associated standard(s) and implementation specifications that correlate with the respective meaningful use objective and measure, they can successfully demonstrate meaningful use even if their exact method differs from the way in which the Complete EHR or EHR Module was tested and certified.”
Adhere to the data and technical standards defined for the objective. The ONC has issued reference grids that show each measure and objective and their corresponding data and technical standards. While you are not required to demonstrate adherence to the data and technical standards during Stage 1, they offer important guidance-and demonstration may be required for Stages 2 and 3. Therefore, it makes sense to do everything you can to adhere to these standards as soon as possible. CMS has issued one- to two-page specification sheets for each measure that are designed to assist you in demonstrating meaningful use successfully and to help you understand the specific requirements of each objective.
Capture the data elements required to achieve the objective and report those elements from the EHR with your vendor-certified reporting logic. The goal is for data capture to occur in the EHR, in real-time, during the healthcare process.
Important Dates for Meaningful Use
November 30, 2011: Last day for eligible hospitals and critical access hospitals to register and attest to receive an Incentive Payment for federal fiscal year 2011.
December 31, 2011: Reporting year ends for eligible professionals. Expected timeframe for CMS to publish the Stage 2 NPRM for public comment.
February 29, 2012: Last day for eligible professionals to register and attest to receive an Incentive Payment for calendar year (CY) 2011.
Spring 2012: Expected date for CMS to publish the Stage 2 final rule.
YOU'LL NEED TO KEEP YOUR EYE ON THE EMERGING REQUIREMENTS FOR STAGE 2 AND STAGE 3, WHERE THE VARIOUS DATA STANDARDS WITHIN EACH DIMENSION BEGIN TO COME INTO PLAY AGAIN.
Once you understand the four dimensions, it's important to appreciate that although the MU measures generally track closely with any existing EHR implementation project, there are details that will demand adaptation of the current effort.
Some of these details affect and must be integrated into clinical workflow. For example, one of the required demographic details includes collection of “cause of death.” If you do not have an existing workflow in place to collect that, you will need to define one that identifies such things as who will collect the information, when they'll collect it, and where they'll document it. Similarly, one of the required “vital signs” includes the collection of height and weight in order to calculate body mass index for all patients. If you don't typically collect this data in all areas, including ones such as the emergency department, you will need to define a new workflow to meet this requirement.
A second detail that multi-entity systems should keep in mind is that having the same software at each hospital will not be enough. Each hospital has to attest separately and be able to demonstrate that their workflow and clinical use of the certified software meets the objectives for each of the measures.
Yet another important detail is that you must continuously monitor a significant number of data points to make sure you demonstrate compliance with MU over the specified time frame: 90 days for Stage 1 and the full year for Stage 2. This may require dashboards or scorecards for ongoing tracking and trending. If you need help with this, some vendors have tools and consulting services of varying sophistication to measure and monitor the core and menu set measures. Evaluate such tools carefully before buying, to ensure they meet your organization's specific needs.
Taken together, these many and complex requirements will demand changes in nearly any organization. Making that change efficiently and effectively demands an in-depth gap assessment and analysis for Stage 1 attestation and for the proposed Stage 2 requirements, which then leads to creation of a more precise plan, and more targeted execution. You can conduct this process internally or hire an external group, but don't underestimate the effort involved in doing it right.
ASSESS VENDOR READINESS
As you begin the above process, another key issue to consider is vendor readiness. More than 400 vendors already have received certification, which may cause you to believe that your vendor can guide your efforts towards MU incentives, but some vendors are still scrambling to understand the program themselves, which can cause some unforeseen snags.
For example, one large vendor certified a “complete EHR solution,” which included its core product along with five optional modular products. When a client realized its implementation included only two of the five modular components, the vendor had to go back and certify each of its products independently. This enabled the client to use the core product and two of the modular products to qualify for some of the EHR incentive measures. It also set the stage for other clients to put together a variety of modular combinations, based on their unique implementations, in order to use the certified software to qualify.
With these potential complications in mind, one of the first things your project management team should do is to carefully verify that the way your vendor (or a prospective vendor) has certified its products matches how you use or will use the products in your facility in the context of each MU measure. One useful starting point is the ONC's Certified Health IT Product List website, which shows how each vendor certified its core product and any modules.
WORTH THE EFFORT
These are only the initial challenges, and so make clear that attestation is a serious undertaking. It requires a vigilant, ongoing effort that involves the entire organization and never loses sight of both short and long-term goals. You must create a structure for your MU program within the context of your organization's overall strategic plan, engage in a serious project planning and execution effort, and carefully assess your EHR vendor. Looking ahead, you'll need to keep your eye on the emerging requirements for Stage 2 and Stage 3, where the various data standards within each dimension begin to come into play again.
Yet despite the intensity of these demands, it's also important to remember that there are significant returns available that are not limited to the EHR incentives. Electronic connectivity for health data exchange is the direction in which healthcare is moving. Everyone understands the potential for secure and accessible EHRs to facilitate a better, safer, more efficient healthcare delivery system when a patient-centric record exists that spans time, crosses care venues, and extends across different healthcare organizations. So, with a strong plan in place, now is the time to move ahead.
Judy Murphy, R.N., FACMI, FHIMSS, is vice president-information services at Aurora Health Care in Milwaukee, Wis.; a HIMSS board member; co-chair of the Alliance for Nursing Informatics; and a member of the federal HIT Standards Committee. Bob Schwyn is a former CIO of a pediatric medical center, and currently associate principal and meaningful use practice lead, for Aspen Advisors LLC, Pittsburgh, Pa. Healthcare Informatics 2011 December;28(12):31-35