EXECUTIVE SUMMARY:
Nationwide, CMIOs in every type of hospital organization are developing strategies for leading their clinical, IT, and administrative colleagues forward through the complex area of quality data reporting under meaningful use. Those CMIOs in organizations at various stages along the journey agree that it will require a subtle combination of persuasion, sharing evidence and data, and a lot of granular hard work in order to get their clinician colleagues fully on board.
Among the small number of hospital organizations to complete the attestation process on April 18, the first day in which attestation of the fulfillment of the Stage 1 requirements for meaningful use under the Health Information Technology for Economic and Clinical Health (HITECH) Act was possible, was the 11-hospital, 24-facility, 4,100-bed Texas Health Resources (THR) integrated system, based in Arlington, Texas. “We felt we were meaningful users, so why shouldn't we attest?” says Ferdinand Velasco, M.D., THR's CMIO.
Texas Health Resources may be ahead of most of its peer organizations when it comes to meaningful use attestation, but, as its CMIO, Velasco has been facing up to the same challenges as his physician informaticist peers nationwide when it comes to leading some key meaningful use-related processes. Among these are some of the most challenging aspects of MU, particularly those around quality data reporting. So what has it been like for CMIOs as they've been leading their colleagues forward in these areas?
“Pulling together the various groups” in order to move forward in this work “is one thing,” says Velasco. “But there's a learning curve involved for everyone, even for clinical informaticists, who may not have a background in clinical quality reporting,” he notes. Among the process challenges: “You have clinicians accustomed to the manual forms of reporting; they expect you can just push a button. But you really have to take it measure by measure, whether it's VTE prophylaxis, discharge instructions for stroke patients, or emergency throughput measures,” he says.
THE WAY I PRESENT IT TO PHYSICIANS IS THAT THE MEANINGFUL USE REQUIREMENTS, IF YOU REALLY LOOK AT THEM, ARE ALL ABOUT IMPROVING PATIENT SAFETY, PATIENT OUTCOMES, AND COMMUNICATIONS WITH YOUR PATIENTS. SO IF WE DO THIS RIGHT, IT WILL BE BETTER FOR THE PATIENTS.-BRIAN PATTY, M.D.
What's more, Velasco emphasizes, “One of the learnings is that there is a gap between the goal-to be able to extract quality indicators from our electronic health record systems-and our ability to do so. Prior to the HITECH Act, in hospitals, we've largely relied on human chart abstraction-human beings painstakingly looking through records; while on the ambulatory side, we've primarily relied on claims data.” Of course, he adds, “In the first year, all that CMS [the federal Centers for Medicare and Medicaid Services] requires is the capability to do reporting. There is not the requirement yet that what we've been doing manually be faithfully reproduced yet electronically.” The next challenge for his organization: testing the ability to begin automated quality outcomes data reporting.
MOVING AHEAD IN MINNESOTA
Another organization that is moving ahead is the three-acute-care hospital, 19-clinic integrated system in the Twin Cities metro area in Minnesota, the HealthEast Care System, based in St. Paul. HealthEast would be capable of attesting to Stage 1 MU later this year, reports vice president and CMIO Brian Patty, M.D., but, he says, “We opted out of 2011, just because the turnaround on submission for Stage 2 was going to be too tight. You would only have four months to get the code from your vendor, get it installed, and get going on Stage 2, because of the fact that the final rule for Stage 2 will be published in July of next year, and you'd then only have three months to attest in October,” Patty notes.
That having been said, Patty says, “We're doing a lot of internal reports right now on each of the measures” required to attest on. What he and his colleagues are learning, Patty says, is how challenging it can be to ensure the full reporting of various measures, when such requirements run smack into the realities of day-to-day clinician workflow. One example of this has to do with the requirement that “More than 50 percent of all unique patients age 2 and over should have height, weight, and blood pressure recorded as structured data.”
That requirement may sound straightforward to non-clinicians, but here's the tricky part: “Nurses initially said to us, ‘Sure, we're certain we're recording 80 percent of vitals on a regular basis,’ but when we actually ran the report on that measure, we found that we were only at 40 percent, because height wasn't being regularly recorded,” Patty says. “Height wasn't thought to be useful data,” he reports, “because it wasn't used regularly.” In other words, meeting that particular MU requirement will mean requiring nurses to regularly record patients' height measures, even though that one data point is not normally useful to them, and will thus demand the insertion of possibly irksome extra tasks into nurses' day-to-day workflows.
It's just such process-driven learnings that emerge when an organization begins the serious work of fulfilling the data-reporting MU requirements, Patty says. Doesn't that inevitably mean that a large portion of what CMIOs are doing will inevitably involve getting clinicians of all disciplines on the same page, and educating them as to what the requirements are and why they needed to be fulfilled? “Yes,” he says, “that's a big part of the work. Getting the systems installed and running is a lot of the work, but getting people to use the systems in a certain way and to move forward on process improvement work, is another big piece of work.”
Fortunately, Patty says, HealthEast's clinician culture is a very positive one, and he's fortunate that “The physicians are on board; we have very engaged physician leadership here. They get it,” he says; “they understand that there's not a nickel in it for them on the inpatient side, but that it's good for the health system. On the inpatient side, there's no skin in the game for them. But the way I present it to physicians is that the meaningful use requirements, if you really look at them, are all about improving patient safety, patient outcomes, and communications with your patients. So if we do this right, it will be better for the patients.”
ONE THING THAT WE'VE SEEN AS A BIT OF A CHALLENGE ON THE INPATIENT SIDE HAS BEEN THE REQUIREMENT FOR POPULATING OUR PROBLEM LIST. IT'S AVAILABLE IN OUR BASE SOFTWARE, BUT WE'VE NEVER USED IT BECAUSE, ONE, IT'S JUST NEVER BEEN A PART OF OUR WORKFLOW FOR DOCUMENTATION, AND TWO, IT'S A MANUAL PROCESS.-MICHAEL WESTCOTT, M.D.
Patty says he also makes sure to emphasize to HealthEast's physicians that “There are dollars involved, which we can use to invest in things that will further improve patient care. But fundamentally, it's the right thing to do. And looking at all these requirements from the government, there are no physicians here saying we shouldn't be doing this. Instead, as we focus on how this will improve our outcomes, patient safety, and other [valuable characteristics], and they resonate to that message.”
TACKLING THE CHALLENGES AS THEY COME
At the Alegent Health integrated system, which encompasses nine acute-care hospitals in Nebraska and Iowa, CMIO Michael Westcott, M.D., is also helping his clinician colleagues dig into the deep dive of meaningful use's data-reporting requirements. On the one hand, Alegent has a big leg up in terms of having spent several years now publishing its patient care quality outcomes publicly, both in local newspapers, and more recently, on its organizational website. So the health system already has a real track record in terms of working with clinical data for reporting purposes.
On the other hand, Westcott reports, as his organization moves forward into rolling out computerized physician order entry (CPOE) go-lives, that “One thing that we've seen as a bit of a challenge on the inpatient side has been the requirement for populating our problem list. It's available in our base software, but we've never used it because, one, it's just never been a part of our workflow for documentation, and two, it's a manual process. You can go in and pick a diagnosis, but your clinicians usually don't fill that out to the fourth or fifth digit.” As a result, he says, “We're going to start with having care managers, or nurses, doing it. They will basically extract something from the physician documentation and put it into the chart.”
So what kinds of advice would these CMIOs give their CIO and CMIO colleagues nationwide?
“I think your messaging has to be around patient safety and quality of care; and you have to be able to make that case, saying, this is why we have to use CPOE, and so forth,” says HealthEast's Patty. “Ultimately, there is enough evidence in the literature out there showing that, for example, barcoded meds administration with an eMAR [electronic medication administration record] is safer; there's no argument about it.”
What's more, Patty says, whenever CIOs and CMIOs and their teams can document patient safety or care quality improvement through automation, they should absolutely do so. For example, he says, “We've done some tracking of orders in CPOE, and have tracked how long it takes for a stat med to get to a patient-to get processed by pharmacy, released to the nurse, and administered by the nurse to the patient. And in a CPOE environment, it now takes 15 minutes for a CPOE-ordered med versus 45 minutes for a non-CPOE-ordered med, because in order for a med to be administered under the old paper-based system, the unit coordinator had to take the order out of the chart, and fax it to the pharmacy, and then the way the pharmacy's work queue works, they're not immediately alerted to a stat order via fax, whereas they are when it's a CPOE-driven order.”
Alegent's Westcott adds that the time is coming when the vast majority of hospital organizations will need to transition to mandating use of CPOE, not only in order to achieving meaningful use, but also in order to benefit from the evidence-based order sets and other forms of clinical decision support embedded in CPOE systems. “Even taking the money out of the equation, this is just the right thing to do,” Westcott says. “And we've reached the point where you have to do the right thing. There was a study in the Journal of the American Medical Association from Sweden that showed a dramatic improvement in outcomes from applying evidence-based medicine to cardiac care. And if we know that providing a patient with a beta blocker at the right time is the right thing to do, we should ensure that that kind of thing is done.” (The lead author of that 2011 study was Tomas Jernberg, M.D., Ph.D., and its title is “Association Between Adoption of Evidence-Based Treatment and Survival for Patients with ST-Elevation Myocardial Infarction.”)
Further, Westcott adds, “The second thing I want is for the doctors to focus on their critical thinking-I don't want them to be sitting there wondering how to log on and find order sets, and so on; I want them not to have to be thinking about the mechanics of computing. And I want to make it hard for them to make mistakes.”
Finally, says, THR's Velasco, “Our biggest challenge” in moving forward on quality data reporting under meaningful use “has been the educational gap, educating people that it's not just an automated version of what we did manually with chart abstraction. Once we understood that, it was a matter of filling in the gaps. So, for CMIOs, my general advice is to partner with the quality people, the clinical informaticists, and the core IT people who may not have clinical backgrounds. You need to get those people together as quickly as possible, because even if you're not going to attest this year, the sooner one starts, the better.”
Healthcare Informatics 2011 July;28(7):22-27
