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Putting It All Together

December 26, 2011
by Mark Hagland
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A new CSC report looks at the crosswalk between healthcare reform and HITECH requirements



In early December, Erica Drazen, Sc.D., managing director, and Jane Metzger, principal researcher, in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices at the Falls Church, Va.-based CSC, released a new research report, “Ten Principles for Hospitals To Align Meaningful Use with Healthcare Reform.”

Assisted by colleagues Jordan Battani and Caitlin Lorincz, Drazen and Metzger examined in depth some of the data reporting and other issues implicated in the overlap between numerous healthcare reform-driven programs and the meaningful use process under the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health Act (ARRA-HITECH) legislation. Citing the value-based purchasing program, the shared savings program for accountable care organizations, the readmissions reduction program, the healthcare-acquired conditions reduction program, and the bundled payments for care improvement initiative, the authors write in their report that “In this new world, performance matters a great deal. Payment adjustments for VBP and RRP [value-based payment and readmissions reduction programs] begin in FY 2013. By 2015, 4.5 percent of Medicare revenue will be at risk (not including the additional adjustments for the HAC initiative, for which rules are still pending and potential also from the ACO program). In contrast, HITECH meaningful use puts up to 75 percent of the market basket adjustment at risk in FY 2016 and beyond.”

Given such risks, Drazen, Metzger and their colleagues posit what they consider to be 10 principles “for aligning today’s work on HIT with the requirements of the future.” These 10 are:

> Never short-change patient safety
> Ensure the minimum data set
> Put CPOE to work immediately
> Close the medication loop
>  Move measurement to real time
> Focus patient engagement on high-risk patients
> Go beyond testing with health information exchange (HIE)
>  Invest in internal integration
>  Throw the book at readmissions
>  Consider HITECH the floor, not the ceiling

Following their articulation of these 10 principles, the report’s authors go into considerable depth on each principle, gathering together facts from the healthcare reform and HITECH legislation, and connecting those facts with the underlying strategic and tactical implications for providers.

For example, in the readmissions-related section of the report, the authors note that, “Because of the high stakes, work on many HIT capabilities required for HITECH should be focused on patients at risk of readmission. HIT,” they point out, “can provide a critical linkage in new joint programs with medical groups that are heavy admitters of Medicare or other high-risk patients and/or with nursing homes or rehab hospitals to which at-risk patients are discharged. HIE and patient engagement capabilities of HITECH meaningful use are obvious tools to employ in this effort, but so are electronic patient tracking and clinical decision support,” they note. “Readmissions are emerging as the first real test of care coordination in operation, and every hospital will need to leverage HIT effectively to gain a passing grade.”

Shortly after publication of the report, Jane Metzger spoke with HCI Editor-in-Chief Mark Hagland regarding its implications for healthcare and healthcare IT leaders. Below are excerpts from that interview.

Healthcare IT leaders are trying to manage what seems these days like countless priorities.

Yes, and CMS [the federal Centers for Medicare and Medicaid Services] keeps coming out with new pieces of value-based purchasing, which makes things hard to keep up with. HITECH is very time-sensitive, and you’ve got to keep up with that; so the danger is that you just think of keeping up with HITECH as the goal, and you run the danger of not really moving the organization towards the future payment environment, where performance is everything. So we actually came up with three different tactics for aligning the HITECH with healthcare reform—which is really payment reform.

Jane Metzger

What are the top three things they have to do?

We say them on page 2 of the report; you really have to proceed with a safe implementation; and sometimes that means you can’t follow exactly the minimum that meaningful use would allow you to do. The second thing is that we already know enough about payment reform that we know what it emphasizes. And sometimes, we can work on both at the same time, like readmissions. Or, we know that continuity of care is huge under payment reform. And the other thing that we thought was important is that you could run the danger of thinking that if you do everything that’s in meaningful use, you’re “there.” And actually, we’ve already said that you need to exceed stage 1 in some areas; and there are some areas that meaningful use hasn’t touched yet. So these are the three ties between HIT/meaningful use and payment reform that underlie those principles, and some principles relate to one of these, and some relate to all three. And I think that is the piece that is less obvious.

What is your advice for those organizations coming up from behind on progress in all these areas?

I think in some areas, you can do the minimum, but do it in a focused way; or do something between the minimum and the maximum, but in a safe way. Several times in the paper, we said you’re headed to the right end point if you plan appropriately. And you may be only halfway through that plan, and you can meet meaningful use, but you can still prepare correctly for the future.

So the key problem is shortchanging strategic planning?

Yes, or inadvertently creating problems or going down a detour. Creating problems relates to the whole safety thing—creating workflows that don’t make a whole lot of sense to clinicians and that could lead to errors or something worse. And a perfect example of a detour would be not acknowledging that physicians have to maintain the problem list, and setting up some whole elaborate system by which others would be maintaining the problem list; because you won’t be able to rely on the problem list for care or use it for billing, unless physicians maintain it. And it’s the type of detour that could happen, and someday, you’ll have to knuckle down and do it right, anyway.

Admittedly, it’s already a lot to do meaningful use, but at least if you do meaningful use, and you’re sure that every step is a real step forward and a safe step, you’re way ahead of the alternative. I think that’s what this paper is talking about. It does set a different bar. However, where we’ve said focus your patient engagement on the patients who need it the most—you’re going to be working on patient engagement. And we’ve said, get experience with the patients who need it the most, not necessarily the ones who are easiest. So don’t take the easy way out on patient engagement; put some more effort into it and focus on it; it’s an investment in the future.

One thing that is becoming clear to more and more people over time is that readmissions work is not detached from everything else; it’s related to everything else.

Absolutely; and that’s one of the focus areas we thought made a whole lot of sense as you’re working through meaningful use. Readmissions are really tough, because it isn’t just a readmission to your hospital. And the hospital isn’t going to know as much as CMS knows about where the patient is popping up. So this is really going to emphasize the need for post-discharge follow-up, and really good discharge planning that includes follow-up appointments, and lots of information that the patient understands. So from the hospital perspective, I do think that’s the big test on continuity of care.

Do you think CIOs and CMIOs realize the breadth and urgency involved?

I think it’s pretty hard to keep up with all these programs, and that’s frankly why we’ve done some of the analyses that we’ve done. And one of the problems is that the people in the quality department are likely to have figured this out first—whoever it is who has to read the latest stuff from CMS. So the trick is really to first make sure that all the quality improvement and care management efforts are addressing the issue or heightening the priority of this issue, but then to coordinate this sometimes-separate big project that’s called HITECH. Admittedly, an awful lot is happening, so we thought trying to pull the two together in a rational way could help with the process, because you’ve got some people in an organization watching HITECH, and there are ongoing clarifications, and we’ve still waiting for stage 2; and you’ve got another group paying attention to healthcare reform.


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