Measure Twice, Cut Once

June 24, 2011
Dale Sanders Are you getting the most out of your EMR? In order to qualify for the HITECH incentives from Washington, hospitals will soon be asked
Dale Sanders
Are you getting the most out of your EMR? In order to qualify for the HITECH incentives from Washington, hospitals will soon be asked to demonstrate “meaningful use” of these expensive systems, so savvy CIOs are hard at work today trying to figure out just how their systems are currently being leveraged, if at all.

“I can't imagine any other way of measuring meaningful use if you don't actually measure its use,” says Dale Sanders, CIO of Chicago's Northwestern Medical Faculty Foundation. “In the past, people have tried to use CPOE as the benchmark, which I think is better than nothing. But it's far from everything.”

Celwyn Evans
What's the sense of urgency about measurement? The HITECH timetable calls for meaningful use to be defined by the end of 2009 - in HIT time, basically right around the corner. Hospitals that can demonstrate such meaningful use will qualify for some of the billions of dollars in HIT money promised by Washington. “You can't wait for the definition to come out,” says Celwyn Evans, senior partner at Greencastle Associates Consulting, Malvern, Pa. “Classic clinical transformation technologies are not just ‘add water and go.’”
Linda Reed
Linda Reed, vice president and CIO of Atlantic Health, a multi-hospital system in Morris Plains, N.J., has similar advice. “A lot of CIOs might be waiting until meaningful use is defined. Don't wait - just put a stake in the ground and measure against it.”

The question many are asking is where that stake should go. The four areas that most believe will be part of the meaningful use definition are CPOE, clinical documentation, quality reporting and interoperability; so finding ways to measure the adoption in these areas is a good first.

Some CIOs, however, are asking if it's worth it to try to qualify for the HITECH incentives at all.

The doubts are there for good reason, according to Dave Garets, CEO of Chicago-based HIMSS Analytics. Garets says only 388 hospitals out of 5,172 have the technology in place to document what many think will be meaningful use, though another 1,914 are within striking distance and will likely qualify within a year.

With numbers so low, Reed echoes a sentiment held by many, especially in these challenging financial times. “If I have to spend $12 to get back $8, maybe that's not worth it,” she says. “But I may need to spend $12 before I get $4 taken away.”

That's because by 2015, hospitals will begin to see Medicare penalties for not demonstrating meaningful use. So the real key, Reed says, will be timing. “Do you need to be ready before the money starts, or do you just need to be ready before the penalties kick in?” she asks. “I think it's all very individual.”

Evans says it pays to be ready either way, particularly since the C-suite is well aware of how much money is involved. “What CIOs are worried about is being held accountable to get all this money,” he says. “Many hospitals have built the road and no one's driving on it. That's not the CIO's fault.”

Garets agrees that CIOs should not be completely accountable for the money, and credits HITECH for some positive changes in this area. “What's nice about what HITECH has done is it put these issues on the plate of the executive management team of the hospital.” He says that everyone, from the CFO to the CNO to the COO, has to get involved in measuring outcomes and the impact of IT. “It's going to be an enterprise business initiative that has an IT component,” he says. “And if you don't get it done and wind up getting nailed by the penalties, it's not IT that gets nailed - it's the whole organization.”

Dave Garets
CIOs can start measuring the use of their current systems right now. And many say that an assessment is the first place to start - with or without a consultant - using the four generic steps: determine your standard, gather data, compare to your standard and, finally, address the gap. According to Evans, midsize hospitals using outside consultants can expect to spend between $50,000 and $150,000 on a meaningful use assessment. “But hospitals can't wait until their budget cycle to do an assessment,” he says. “They need to assess right now.”

Evans says simple assessment steps will ensure that CIOs can easily put together a decent business case for IT - and it must be done now, no matter where a hospital is in the budget cycle. “A year from now,” he says, “the Board and CEOs are going to say, ‘We were able to get $8 million and we didn't. Why not?’” Evans says CIOs don't want to be in that position of having to answer that question.”

For those who can't (or won't) perform a meaningful use assessment internally or with a consulting firm, there are always the vendors. Reed, whose hospital is a McKesson shop, says the Alpharetta, Ga.-based vendor was offering a free assessment for all its customers. “I would tap into them first and say to them, ‘How are you going to get me there?’” she says. For vendors, Reed recommends key questions such as which version of their software is certified, and when they are going to get the customer on it. “That's where I would start,” she says. “And I would take it with a grain of salt when you ask your vendor what ‘meaningful use’ means, because they'll probably define it in terms of their product suite.”

Reed says asking her vendor for help worked for her, but Garets says that finding consultants, vendors or any of the above to do a meaningful use assessment isn't going to be easy going forward because that whole market is about to explode. “You could ask your vendor, but there are going be vendors like Meditech that say, ‘Sorry, you're on your own, we don't have the resources for that.’” Garets says CIOs need to analyze the resources they have on staff and figure out where they're going to get the additional help. And the earlier, the better, he says. “There are only a finite number of human beings that have the training and experience.”

But according to Sanders - who has been measuring the use of his Epic system for more than a year with a simple tool he developed - assessing meaningful use is not overly burdensome to measure. “It's more the length of time,” he says, noting that direct observation made it clear to him that the doctors could be doing more with Epic. “If you really believe what's important about an EHR is the data you get out if it, then start from that and work backwards,” he says. “That's a good way to build your implementation strategy, and then it becomes up to you to define meaningful use, at least in some degree.”

Measuring data is nothing new for hospitals. But in this brave new world, Garets says, the rules have changed. “The problem is that it has to be process, as well as quality outcomes measurements.” In fact, Garets says, for generations, hospitals have been proving quality outcomes and patient safety outcomes by measuring claims data or hiring HIM management professionals to do chart pulls. “Neither of those is a measure of an advanced electronic record,” he says. “You've got to include process outcomes, not just patient safety and quality, and you've got to have process measures.”

In the case of CPOE, for example, a process measure will track what percent of orders are issued by physicians in the computer system, and that number is then tied to outcomes. “It doesn't say the orders are better, but it's a measure of how you used advanced technology,” says Garets. “You've got to have some process measures. What we've got to do is figure out what those process measures are.”

And when it comes to process measures like CPOE, the HITECH incentives may make the hospital C-suite play hardball with their docs. Reed says a lot of people don't want to rock the boat and mandate CPOE. However, she does say that the stimulus package might mean a firmer input from the hospital leadership suite. “If you have to drive some very deep adoption very quickly, you're going to need some mandates,” she says, adding that those mandates should be driven by leadership. “Otherwise you can't say to me as CIO that I'm responsible for not getting this money.”

It may not be necessary for everyone to mandate process. However, sometimes gentle guidance can work, as Sanders points out. “We're very cautious about dictating and mandating by policy the way we use Epic around here,” he says. “If we're not courageous enough to embrace policies that require utilization in a certain way, we at least need to have some guiding principles.” And Sanders lays out these principles in a one-page document on utilization and proper use (see sidebar). “This was not some kind of heavy top-down thing; it was just nudging people in the right direction.”

In the end, many say, meaningful use and its incentives will be more about the process than about the technology. According to Reed, information technology is becoming more about the information and less about the technology. “When you ask, ‘How do you get information, and how do you get people to use systems,’ you're really talking about working relationships.”

Garets agrees. “We're not putting this technology in to improve technology, we're putting it in to improve quality,” he says. “But you've got to measure how you are using the technology, because once you get on this freeway, there are no exit ramps.”

Healthcare Informatics 2009 July;26(7):24-28

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