With the help of an early start on its meaningful use journey, Cottage Hospital, a 25-bed critical access hospital (CAH) in Woodsville, N.H., completed its 90-day attestation period on July 15 and received Stage 1 meaningful use certification the same day from the Center for Medicare and Medicaid Services (CMS). Cottage Hospital joins 100 other hospitals and more than 2,300 eligible providers that had completed the attestation process as of July 8, according to CMS officials.
Cottage Hospital is the first critical access hospital in New England to achieve Stage 1 meaningful use and successfully attested just two days after a much larger provider. In all, there are 1,327 certified CAHs located throughout the U.S., with Cottage Hospital being one of 13 in New Hampshire.
CAHs are significantly less likely than other U.S. hospitals to adopt key applications that are preconditions for meaningful use, according to a policy briefing from the Rural Health Research Centers at the Universities of Minnesota, North Carolina-Chapel Hill, and Southern Maine (the Flex Monitoring Team), which were the recipients of a five-year cooperative agreement award from the Federal Office of Rural Health Policy to monitor and evaluate the Medicare Rural Hospital Flexibility Grant Program (Flex Program). Fewer than 14 percent of CAHs have an electronic medical record (EMR) with a clinical data repository and some clinical decision support capability, while the most frequently adopted technology applications are order communication systems, which have been adopted by almost two-thirds of CAHs, and radiology picture archiving communication systems (PACS), which have been adopted by over half of CAHs.
Not only did Cottage Hospital conquer an uphill battle that is meaningful use despite its limited resources, it accepted no federal funding to help implement its health IT. Cottage Hospital attributes its rapid Stage 1 success to the facility’s long-term commitment to technology and teamwork, beginning 10 years ago when it implemented its EMR, from the Nashville-based Healthcare Management Systems Inc. (HMS). The mandate for EMR implementation came from the top, with the CEO realizing that technology was the direction patient care was heading. All the meaningful use requirements did for Cottage Hospital, according to Gary Tomlinson, director of management information systems, was to define a timeline for implementation.
Cottage Hospital did, however, work closely with the Regional Extension Center of New Hampshire, which provided helpful tools and “a lot of clarification.” “Our REC contact came to Cottage a few times and even attended one of our meaningful use committee meetings,” says Tomlinson. “The REC helped us make sure that we were ready to go as an early adopter. In fact, they gave us a tool that helped us measure our readiness, and that gave us the confidence to move forward.”
Over the past 10 years, Cottage Hospital has added modules to its EMR and additional interfacing systems like a PACs, eMAR, and automated medication dispensing system. Once the final rule for meaningful use Stage 1 came out, Cottage Hospital did a GAP analysis to find out what requirements still needed to be addressed and what thresholds for core and menu items still needed to be met. Items like allergy lists, demographics, and vital signs needed to be elevated, as they did not meet the minimum thresholds.
Challenging Core Item: CPOE
One of the hardest Stage 1 items for Cottage Hospital to achieve was computerized physician order entry (CPOE). With more than 70 percent of orders occurring electronically via computerized provider order entry (CPOE), Cottage Hospital easily eclipsed the Stage 1 minimum CPOE threshold of 30 percent. There was, however, some initial pushback from primary care physicians on changing medication order workflows, so Tomlinson took another approach.
“I took a look at where do most of the inpatients get admitted from, and it turns out that 68 percent of patients were admitted through the emergency room,” Tomlinson says. So he focused on working with those physicians to order their medications using CPOE, so he could eventually more than double the minimum Stage 1 threshold.
One facet of the Stage 1 requirements that proved easier for Cottage Hospital to obtain was incorporating at least 40 percent of test results into its EHR as structured data. Cottage Hospital managed to reach 84 percent, and has been capturing results electronically for four years.
This strong history of electronic lab result capture also led Cottage Hospital to achieve another menu item of performing a test for submitting electronic data on reportable laboratory results to public health. For several years it has been sharing electronic lab results with neighboring non-affiliated clinics, one of which is a federally qualified health center (FQHC), via a HL7 router. Tomlinson says this puts Cottage Hospital in a good place to achieve Stage 2 core item of exchanging clinical data via a care of continuity document (CCD).
A meaningful use committee representing the entire hospital from clinical to business to the board of trustees was assembled and enabled Cottage Hospital to move forward to tackle Stage 1. “I got all the major directors from the clinical side, and they saw the value and where this was going to improve patient care,” says Tomlinson. “I couldn’t approach this as an IT project because it would never fly.” He adds that the financial incentive didn’t sell meaningful use for his organization and that stakeholders had to see benefits in patient care for them to come onboard.
One of the biggest challenges for Tomlinson was finding the manpower for the massive undertaking. Not only was Tomlinson project leader for Stage 1, he’s also the department head, which includes handling other tasks beyond meaningful use like overseeing help desk activities and maintaining networks. Because the IT department has only four members and a few part time clinical informatics, the onus relied heavily on clinical department heads. Tomlinson convened status meetings every two weeks to discuss implementation and challenges. “It was like a sanity check to make sure if someone on the team was stumbling, then the rest of the team could help that person,” he says. He remembers one particular director of the med/surg department, who had five Stage 1 items that had to be lifted to meet the minimum threshold, and more than anything she needed moral support from the team. Much of her work entailed having nurses incorporating IT into their workflows, but once they got to use it became natural and intuitive, Tomlinson says.
Despite limited human resources for the project, Tomlinson says being nimble was key to Cottage Hospital’s success. “You can work more closely in small environment like this,” he says. “You can go to your critical directors and sit down and have a talk with them to make this all work. Perhaps in a larger organization, it can be that much more difficult. Where we had the advantage that we were just smaller and were able to bring a closer group together.”
CAHs are moving forward on slightly different rules for meeting meaningful use. For more specifics, click here.