Washington County Hospital is a 22-bed critical access hospital located in Nashville, a town of 3,258 in a rural, agricultural part of far southern Illinois. The hospital counts 185 employees, 120 of them full-time, and the rest part-time, and has an IT department of four full-time people, one of whom is CIO Kim Larkin. The hospital’s medical staff includes 12 physicians, some of whom are employed. Larkin spoke in early December with HCI Editor-in-Chief Mark Hagland regarding her team’s meaningful use journey to date. Below are excerpts from that interview.
Could you explain for our readers how critical-access hospitals are participating in the meaningful use process under the HITECH Act? Are they participating in a separate program?
It’s all the same program, but how we get paid is different. We are a cost-based hospital under Medicare. And the meaningful use incentives are structured differently. There’s a formula for critical-access hospitals that allows us to recoup the funds invested in our EHRs [electronic health records] based on the costs based on what we’ve spent; it’s based on our Medicare percentages, and in addition, there’s the potential to have a bump of 20-percent over that. Effectively, that put us at 100-percent reimbursement; so for every dollar we’ve spent on meaningful use, we are eligible to have Medicare reimburse us for that. The downside is that we had to have the cash available upfront, which was a challenge. We completed the attestation period on September 30, and we submitted about $740,000 to the feds.
Have you received a check yet?
No. I actually did the attestation on the website on October 6. We have to send all our receipts to our fiscal intermediary [in order to move the process forward]. And the week of Oct. 17, I sent in our receipts to the fiscal intermediary. And we actually had to send in copies of paid invoices. And we sent it to our fiscal intermediary, after reviewing every single invoice with the CEO and CFO. The three of us sat down and went through the invoices and made sure we agreed on everything being included. They’re saying eight weeks from submission. And we’re expecting to get about 70-75 percent in that check; the remaining amount will appear in a cost report; that additional 25 percent or whatever it is, when we file our cost report at the end of April 2012, we will file our cost report next autumn; and when we file that cost report, we’ll receive the remaining monies. [As of the date of the publication of this interview, Larkin was waiting to hear about the amount her hospital would receive in its first payment.]
So we had to have the money upfront, which means that there’s a huge cash flow issue for any critical-access hospital. And that amount is huge for us; we basically operate with almost no margin. We’re cost-based, which means that we have no reserves. Some months, we barely break even. Most critical-access hospitals are pretty close on that bubble; they exist, because they provide critical services to their communities. So we have been struggling this last year, 18 months, financially, just because our reserves have been going into IT. We haven’t made any capital investments.
Am I correct that critical-access hospitals would not see reimbursement cuts if they didn’t do this?
Well, we’re not paid based at all on performance, but the consensus among the leaders of critical-access hospitals in Illinois and nationwide, is that at some point, Medicare will require this of us.
You have a very small IT staff with which to accomplish all the meaningful use requirements.
That’s true, but we can also be very nimble. And just because we’re small doesn’t mean we don’t need the voice of the CIO, working with the strategies and the board. We have to do the same things bigger hospitals do. And actually, the patient safety piece around electronic health records probably drove us as much as anything else. So the reason for us doing this now is that we already had the EHR from NextGen [the Horsham, Pa.-based NextGen Healthcare] in our ambulatory clinic.
In fact, we had had ambulatory up and running for three years before we went live inpatient [both with the NextGen solution]. And we had had physician documentation, the medication list, etc., live there. So it was not hard to sell this. And the physicians were literally walking across the hallway between inpatient and outpatient. And we employ physicians in our rural clinic. So we did the entire inpatient implementation without adding a single FTE to the hospital. It wasn’t an option; so we did what we had to do.
How did you do it?
The fact that we were able to do it at all attests to the leadership of our CEO, Nancy Newby, R.N., Ph.D., who had been our CNO before being CEO. She stressed to our board and employees that we needed to do this and had to do this. And when things got difficult, which they always do, she stood firm.
The fact that she’s an R.N. by background probably helped a lot, didn’t it?
Absolutely. And there was none of this going over my head or anything; and even if the staff and physicians had challenges with the workflow changes—and that’s always the big thing—that truly made it work. It was simple: the message was, we have to do this—and if they didn’t like the way I was handling this, we would ask them what their suggestion was. But as we told the physicians, you have to put your orders in. And sometimes, I was able to say, sure, you can do that a certain way. In other cases, I had to tell them, I’m sorry, but there’s no way we’ll meet this requirement if you don’t do it this way.
Tell me a bit more about your medical staff?
We have 12 on active medical staff. We employ four physicians in our rural health clinic. We have two or three other physicians in the community who are employed elsewhere and who admit to us. And our ED is staffed through a contract with an ED group. So when you add those doctors, I’ve got about 15 users on the inpatient side.
So the biggest challenge was helping clinicians through workflow changes?
Yes, apart from the cash challenge. But they were accustomed to walking down the hallway and saying, give me an x-ray. And now they have to do this electronically. And for medication reconciliation, the paper-based and electronic processes are totally different, because to do it in the computer means it’s actually the physician doing the med rec [medication reconciliation], and not the nurse. So that’s a huge change.
I would think that people feel adept, accomplished, now?
Yes, I think so. And we are still going in and doing chart audits, and checking for completeness. If we get a new nurse, and we make sure their charting is optimal. I’m still running all of the meaningful use reports, even though we did attestation. And I was really excited at the end of October—when I ran everything again at Oct. 30, we were at an even higher compliance level than we had been at the end of the 90-day attestation period, which ended on Sep. 30, which that tells me that the clinicians had routinized their work processes. We were at almost 100 percent on every one of those measures, and our board was very pleased. And you can’t put stage 2 on top of stage 1 unless you have stage 1 running flawlessly. And if you put something on top of it, the previous work holds it up.
What would your advice be to CIOs of other small, including critical-access, hospitals?
We’re already providing some advice to some of our colleagues, through the Illinois Critical-Access Hospital Network; 50 of the 51 critical-access hospitals in the state are members. It’s an official organization, and has worked collaboratively on all sorts of different issues.
Were you the first critical-access hospital in Illinois to do this?
No, ten of us all did our attestation at about the same time, in October. And that was huge; I was so excited to do that. And it’s great, because if one person in the network is having trouble with something, others help them. And once I had done my attestation, another hospital came along and asked us for help. We’re not competitors, and our service areas don’t usually overlap. So it makes for a very open relationship and collegiality. So yes, 10 of the critical-access hospitals in Illinois did this. And we were actually the first NextGen hospital in the country to attest, which I didn’t realize at the time.
Would you like to add anything else?
You know, I think it’s a difficult process for everybody. Money is an issue for all sizes of hospitals. I think it’s hard for everyone, and I don’t think there’s a one-size-fits-all implementation plan that you can turn to. And I think people run into problems when they try to find an implementation plan online and follow that. Here, if I have one person out on sick leave for three weeks, sometimes our only option is to delay things for three weeks, because we just don’t have enough people. So my advice is, don’t try to ‘cookie-cutter’ it. And the goal here really, really needs to be to improve patient care, patient safety. Because the rewards here are to improve patient care and offset some of your costs—and not even all of your costs. The end game is to improve care and the view of the patient. And whether it’s a critical-access hospital or a huge system, we’re all in the same boat in that regard.
