Research by Matthew Weinstock

For most of 2009, vendors, hospital leaders and other industry experts professed to know what it will take to achieve meaningful use of electronic health records. But then the Centers for Medicare & Medicaid Services in December issued its proposed rule. As IT experts read through the 500-plus pages, it became clear how far providers had to climb.

Rick Pollack, executive vice president at the American Hospital Association, says the proposal creates a "stringent definition of meaningful use that doesn't recognize" the work hospitals and physicians have already done to deploy IT and improve quality and safety. Other groups also expressed concerns. The AHA has filed comments with CMS in hopes of creating a more flexible final rule; one that "would reward the progress hospitals and physicians already have made toward adopting EHRs," Pollack says.

Although much could change by the time a final rule comes out this spring, hospital officials now have a roadmap to follow. Importantly, it is not just about IT deployment, says Pam Arlotto, president and CEO, Maestro Strategies, a consulting firm in Roswell, Ga. There is a strong quality focus in the rule."What you should do first is say, 'What is our goal here? Are we trying to install IT or are we trying to improve care?'" says G. Daniel Martich, chief medical information officer at the University of Pittsburgh Medical Center. The answer should be the latter and if that's the case, he says, a lot of work needs to be done before flipping the switch on an EHR: standardizing order sets, creating more efficient work processes, and more. "If you automate bad processes, you are not going to get better," he says.

Assess Yourself

It is time for hospital leaders to step back and evaluate their organization's IT status. That's not to say this is a time to rest. CMS' final rule will come out in the spring and the compliance clock starts ticking in October, which is the beginning of the federal fiscal year and when hospitals become eligible for incentive payments. But before hospitals can think about applying for the enhanced reimbursement, officials need to know where they are and where they are going, experts contend. Maestro Strategies' Arlotto says the assessment must go beyond the IT department. "This is not just an implementation roadmap; it is bigger than that," she says. "It will change your overall strategic plan and your investment strategy." Linda Reed, R.N., vice president and CIO at Atlantic Health, adds that a thorough assessment will help hospitals figure out when they'll be ready to reach Stage 1 and apply for an incentive. For those that are at the very early stages of IT rollouts, an assessment will help identify gaps that need to be addressed and avoid the penalties that start in fiscal 2015. An enterprisewide assessment should include several factors, such as:

  1. Assess EHR deployment on the organization's strategic and investment plans.
  2. Assess the impact on other IT projects.
    Do you need to re-prioritize?
    Do you need to set new expectations with leaders?
  3. Assess the gap between current capabilities and the proposed rule and your ability to catch up.
  4. Determine if it is more prudent for your organization to undertake a rapid rollout so you can apply for incentives versus taking more time with an eye toward avoiding penalties.

Setting the Stage

Rather than require hospitals to meet meaningful use criteria by specific dates, CMS proposes a three-phase approach. The proposed rule issued last December addresses Stage 1; rules for Stages 2 and 3 are forthcoming. While the push is for hospitals to become meaningful users as rapidly as possible, CMS officials say the phased approach recognizes that there is a wide range of IT deployment levels. A variety of reports and studies were issued in the days immediately after the proposed rule came out suggesting that providers are not very far along in meeting the CMS criteria.

STAGE 1
Electronically capture health information in a coded format, track key clinical conditions and communicate outcomes for care coordination, implement clinical decision support tools to facilitate disease and medication management, and report outcomes for public health purposes.

Key Stage 1 requirements for eligible hospitals:

  • Using a certified EHR and meeting 23 proposed criteria; 17 objectives require attestation by the provider, the rest will require that information be submitted to CMS.
  • Hospitals are eligible for Medicare and Medicaid incentives if they meet volume thresholds; physicians must choose between the programs.

STAGE 2
Will expand on Stage 1 to focus on continuous quality improvement at the point of care; greater use of CPOE is likely, as is more robust exchange of health information.

STAGE 3
Will focus on "promoting improvements in quality, safety and efficiency" with an emphasis on decision support, patient access to self-management tools, access to comprehensive patient data and improving population health.

Source: Centers for Medicare & Medicaid notice of proposed rulemaking, Dec. 30, 2009

An Incentive for Early Adoption

Despite the staged approach, the enhanced Medicare and Medicaid reimbursements are clearly designed to encourage providers to roll out EHRs sooner rather than later. Under the proposal, eligible hospitals could begin to apply for the incentive in fiscal 2011 if they meet Stage 1 requirements and fulfill them continuously for any 90-day period during the fiscal year. Meaningful use would have to be achieved year-round in successive years. Hospitals can wait until 2012 or even 2014 to achieve Stage 1, but the amount of the incentive will shrink and there will be less time to meet Stage 2 and 3 requirements. For instance, a hospital achieving Stage 1 in fiscal 2011 has two years to achieve Stage 2 and four years to reach Stage 3. A hospital waiting until 2013 to get to Stage 1 would have only one year to reach Stage 2 and two years to reach Stage 3.

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Are You a Meaningful User?

CMS proposes that hospitals meet 23 objectives to be deemed a meaningful user of an EHR. The agency's proposed rule organizes the criteria around five broad policy objectives that apply to Stage 1 implementation. Here's a sampling of what CMS proposes. The full list can be found in the notice of proposed rulemaking.

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