EXECUTIVE SUMMARY:
Even the best-positioned hospital and health system organizations have been struggling with some aspects of meaningful use. What are the implications of their struggles for the path forward into Stages 2 and 3? A look at the current challenges on the ground, and the path ahead.

At about the same time this issue of Healthcare Informatics hits your inbox, so will the Notice of Proposed Rulemaking for Stage 2 of meaningful use under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (ARRA-HITECH) Act of 2009. And if the pattern from Stage 1 holds true, there will be several months of tension as provider and vendor organizations push back against regulators, advising the Centers for Medicare & Medicaid Services (CMS) that the new measures are too heavy to lift.

Because of the tight timelines they were facing, the advisory committees of the Office of the National Coordinator (ONC) didn’t have the benefit of much provider feedback on Stage 1 before they had to make proposals for Stage 2. But with more time at their disposal, CMS officials will no doubt weigh both what providers are saying about Stage 1 and the number of hospitals and physicians participating. (Only 10 percent of the 778 hospitals in a September 2011 HIMSS Analytics survey reported having the capability to address all 14 core measures and at least five of the 10 menu items. Another 31 percent of the hospitals should be prepared to meet Stage 1 of meaningful use shortly, reported HIMSS Analytics, a division of the Chicago-based Healthcare Information and Management Systems Society.)

The turn of the New Year provides a good vantage point from which CIOs and other healthcare IT leaders can take a look back at Stage 1, and as they begin to ramp up for Stage 2 apply some of the lessons they’ve learned. We asked a few CIOs where the pain points are and if there are things CMS could change to provide more clarity and flexibility and reduce the reporting burden.

Devil in the Details
Perhaps the biggest surprise to come out of 2011 is the relative difficulty even some of the most sophisticated users of health information technology reported having in working to attest to MU in Stage 1.

At the recent American Medical Informatics Association symposium, Len Bowes, M.D., a senior medical informaticist for the 22-hospital Intermountain Healthcare in Salt Lake City, Utah, described the difficulty his organization is having with software and workflow changes around its homegrown electronic health record (EHR) systems. Intermountain, which has received numerous industry awards for e-health innovation, has to both certify its own EHR systems and get hospitals and physician groups to achieve meaningful use. Its meaningful use project team identified 105 items in a gap analysis. “From a high level, the list doesn’t look too challenging,” Bowes says, “but the devil is in the details.”

Intermountain has bolstered its meaningful use project team to 22 full-time-equivalent employees working on issues ranging from medication reconciliation to problem lists. But reworking computerized physician order entry (CPOE) is the largest challenge, Bowes says. Officials decided that Intermountain had to make widespread changes to get every physician using CPOE in the hospitals, and that is taking time to implement. “We want to get them something that works and doesn’t have redundant workflow,” he says. Intermountain postponed its Stage 1 attestation for hospitals until mid-2013. “If we get half of our hospitals to achieve meaningful use then, it will be good,” Bowes says.

Clinical Quality Measures:‘Premature, Non-standard'
“Simplify and clarify.” That’s Denni McColm’s mantra for meaningful use going forward. The CIO of Citizens Memorial Healthcare (CMH) in rural Bolivar, Mo., is optimistic about the potential value of meaningful use, as well as an outspoken critic of how some of the measures were rolled out. CMH’s 76-bed community hospital attested to meeting Stage 1 at the end of May 2011 once federal officials signaled that Stage 2 would be postponed for those hospitals achieving meaningful use in 2011.


Denni McColm

In October, McColm testified before ONC’s Meaningful Use Workgroup about CMH’s experience. In that presentation and in a recent interview with Healthcare Informatics, she noted that although her organization has achieved Stage 7 on the HIMSS EMR adoption model, it had some serious challenges qualifying for meaningful use in Stage 1, and that other rural hospitals just beginning that journey to EHR adoption have a lot of work ahead of them.

For McColm, several of the Stage 1 items were problematic because they were poorly defined or confusing. For example, although it is standard practice at CMH to provide a summary care/transfer record upon any transfer of a patient to another facility, officials there were unsure about which transitions of care to include in the summary care record measure; or what format or content the summary care record should include; or how to report that the summary care record was provided.

There seems to be a consensus among CIOs that the clinical quality measures are potentially the most important aspect of meaningful use, but they have also been by far the biggest challenge in Stage 1. McColm calls the measures “premature, non-standard and un-owned.” She says the measures do not appear to have been piloted or field-tested and don’t include any guidance for implementation. “Some of the clinical quality measures are half-baked and there is no one to ask about them, no stewards,” she adds. The Joint Commission should be the owner, she suggests. “I think CMS should have waited a year to do clinical quality measures. They would have been better off if they had identified stewards.”

Thomas Smith, CIO at NorthShore University HealthSystem in Evanston, Ill., agrees with McColm about the need to improve the clinical quality measures. “I talked to our quality staff, and they felt the meaningful use definitions were not well thought out,” he says. “ONC needs to work with other agencies. CMS has whole divisions that have spent years working on this.”

Although four-hospital NorthShore attested to meaningful use for both its hospitals and physicians on day one, Smith has stressed to policymakers that the program requires too much reporting. He estimates that approximately 70 percent of the 36,000 employee hours spent on Stage 1 has been on reporting and not on quality improvement. “Seventy percent of the effort shouldn’t be on reporting.

They require us to use a certified EHR that passes certain minimum requirements and that makes sense,” he says. But EHRs in general are not designed to do mass reporting, he notes. CMS could have made some sort of exception for data warehouses to do the number crunching. “We could use the EHR for collecting and using the data but then use a calculating machine that is 10 times stronger. Instead, some of these monthly reports take 12 days to run and we have people here on weekends.”

That data warehouse certification issue is an example of something that should be relatively easy for ONC to go back and revisit, says Kevin Burchill, a director at Beacon Partners, a consulting firm in Weymouth, Mass. “Hopefully, as in Stage 1, what comes out after the public comment period will be better for it and will reflect these types of concerns.”

Another common refrain from CIOs is that CMS has to do a better job of harmonizing all the quality-reporting programs it has in place, including meaningful use, those related to the medical home and to the accountable care organizations program, and Medicare’s Physician Quality Reporting Initiative (PQRI), as well as the requirements coming out of the Washington, D.C.-based National Committee for Quality Assurance (NCQA), and other programs. Each program has its own specific goals, Smith says. “On the surface they may look exactly the same, but when you get into it, what gets included and excluded in the measures is slightly different, so it is a difficult thing for IT to write reports for each. It might be smart to have some sort of CMS portal where we submit all this quality reporting data,” he adds, “and they sort it out on their end.”

Hospitals that are implementing new systems or switching vendors in 2012 to meet meaningful use are doubly challenged, says Burchill. The provider organizations get in queues with vendors, but then have to line up both internal and consulting resources when planning implementation. “So there are capital planning and operating expense considerations, and matching those up is an art,” he adds.

Curt Kwak would agree. The CIO for Providence Health’s Western Washington region, which encompasses three hospitals and a service area that includes 65 Providence-owned clinics, is in the midst of switching EHR vendors. “It will be a challenge to get to Stage 1 next year,” he admits, “but we plan to get through Stage 2 by the end of 2013. We have a team dedicated to meaningful use and have developed a tool to track our progress on all fronts. We also have an informatics office to help define workflow requirements.”


Curt Kwak

Stage 2: 'Aggressive and Ambitious’
Even though providers that attested to meaningful use in 2011 are expected to have until 2014 to phase in Stage 2, they will still be kept busy, because many of the new measures are ambitious. First, all Stage 1 menu measures would become core measures, and would be required of all providers. Medication orders must be automatically tracked via electronic medication administration record (eMAR) in at least one hospital unit. (That requirement has huge patient safety improvement implications, but is an implementation challenge to introduce, McColm notes.) Hospital labs must provide structured electronic lab results to outpatient providers for more than 40 percent of electronic orders received.

Other new measures in Stage 2 involve patient engagement, care coordination, and a greater reliance on health information exchange (HIE). For instance, hospitals would be responsible for requiring that more than 10 percent of patients actually view information about a hospital admission. And more than 10 percent of all discharges must have care summary information sent electronically to a provider or post-acute care facility.

But some CIOs are nervous about how care coordination, patient engagement, and HIE are being addressed. McColm says policymakers have expressed disappointment that more provider organizations haven’t been choosing patient engagement menu items in Stage 1. “We have both a portal and personal health records, and it is still hard for us because of how the measures were defined,” she says. “That should tell them something.”

The patient engagement aspects of Stage 2 are aggressive and ambitious, she adds. “I think that when the proposed rule is announced, some of us should pilot those and get back to them about how hard it is to do. Some may sound easier than they are.”

Smith says NorthShore can probably meet Stage 2 requirements to exchange data with three other hospitals by using Verona, Wis.-based Epic Systems’ tools for exchanging data with other Epic customers in the Chicago area. But for Stage 3, the goal is to exchange with 30 percent of eligible providers in the area. That would be hundreds of doctors on dozens of disparate systems. There is no regional HIE in operation. “We are dependent on a statewide HIE being formed, but Illinois is pretty far behind,” he says. “There is widespread skepticism about whether the HIEs will be sustainable.”

Looking at the proposed Stage 2 objectives, Providence’s Kwak sees challenges around the proposals to develop a list of “care team” members and create more virtual communication among those providing services to each patient. In his organization, there’s a lack of clarity around clinical and nurse informatics roles and responsibilities, as well as their function within information services, he notes. This is especially difficult in a complex system of hospitals and clinics in which you are dealing with multiple standards and environments. “A care team can be established using personnel from the disparate environments,” he explains. “However, getting them acclimated to a standardized set of measures as well as a standardized method of practicing around the new measures will take time.”

Organizations such as CMH, Intermountain, Providence, and NorthShore seem to be in relatively good shape to address their own weaknesses in meeting meaningful use goals. But many other organizations are struggling to pull together the resources, says Fletcher Lance, vice president and healthcare lead in the Nashville office of the Atlanta-based consulting firm North Highland. “Large organizations with the wherewithal are in the process of clinical transformation and can focus on how to best use these tools,” Lance says. “They are adapting their workflows and hiring chief medical information officers and chief nursing officers to drive the change. They are on the good end of the bell curve.”


Fletcher Lance

At the same time Lance says, “There are a lot of hospitals in the center of that curve still struggling to meet the first stage. They can’t yet put any strategic focus on Stages 2 and 3.”

The good news is that the providers are definitely engaged and moving forward on meaningful use goals. Thirty-two percent of CIOs surveyed in September 2011 believe their organization can achieve Stage 2 objectives with or without a delay in the start date, and another 25 percent believe their organization can meet requirements under Stage 2 if the planned Oct. 1, 2012, start date is delayed, according to the College of Healthcare Information Management Executives. For ONC, the trick will be to keep the focus on that progress so it doesn’t stall after the meaningful use dollars are gone. “You won’t have the carrot anymore, but you don’t want to do it with a stick either,” Lance observes. “You want to keep the momentum going as healthcare providers do the hard part of cultural change. You don’t want them to get stymied.” ?