Hitting Snooze on HITECH

The healthcare industry has had many challenges since 2000; beginning with Y2K, which was primarily a technology-focused effort, and then the implementation of HIPAA, which impacted technology, operations and policy. What did the healthcare industry learn it needs to do?

• Plan and plan well - strategically and tactically

• Take action and not be a straggler, as it costs more in the end

• Communicate to all of our staff (leadership, physicians, clinical and business staff, board members and business associates)

• Educate the organization

• Keep the patient and delivery of quality care our primary focus

George Santayana famously said, “Those who cannot remember the past are condemned to repeat it.” In the case of Y2K and HIPAA, too many organizations used the “head in the sand” approach and waited to see what everyone else was doing. By the time they were ready to move forward, most of the technical and professional services needed to assist them were already committed. What was left or available were service offerings and staff that came late in the game from those hoping to capitalize on the opportunity with very little skill sets.

Action Tasks for HITECH

With all that is occurring today, including the economic downturn, challenges in staffing, and healthcare reform, including ARRA, it becomes clear that better scenario-based planning needs to occur, not just strategic 5 to 7 year planning. Organizations must look closer at today's industry drivers and retool their strategies to keep pace with weekly/monthly challenges. The budget plan formulated last year, based on metrics from the previous year, is no longer applicable.

The IT strategic plan needs to be created to support - and integrate with - the organization's strategic business plan. That's not a new concept. However, the need to visit and revisit the operations, workflow, and relationships with physicians, patients and regulatory agencies will be required in order to identify and prioritize/reprioritize budgets, tools and schedules. There will be a need to focus on continual restructuring of plans to meet the ever-changing environment - being late may not be an option.

So at what point do you “break the glass case” of your strategic plan and revise projects and strategies in order to respond to unexpected opportunities or challenges? You do it in the event of regulatory changes, economic hardships, or business opportunities. The Health Information Technology for Economic and Clinical Health (HITECH) Act falls under all of these categories.

As we look at revising strategic plans to fit a new clinical system, we need to recognize the challenges inherent in the healthcare industry. Healthcare is more than a building or a person who cares for the ill; as such, we cannot always draw examples from other industries. We are a fluid process, with complex procedures and a high level of variance of clinical challenges. In healthcare, we are a community, and we need to deliver quality care to patients and address disease management.

Inserting a complex clinical system to document, maintain, interface, produce and report clinical information is a daunting task. We now have an opportunity to implement an EHR and address one of the biggest concerns faced by CFOs in championing such a system: “Where's my return on investment?” The HITECH Act promises to provide significant financial incentives through the Medicare and Medicaid programs to encourage doctors and hospitals to adopt and use certified electronic health records. Physicians will be eligible for $40,000 to $65,000 for showing that they are meaningfully using health information technology, such as through the reporting of quality measures. Hospitals will be eligible for several million dollars in the Medicaid and Medicare programs to similarly use health information technology.

HITECH Funds for Providers

Estimated Funding Available for Hospitals

Although the focus has been on the technology component of the Stimulus Bill, there are HIPAA and compliance issues that need to be addressed as well; we cannot lose sight of the entire Act and the resulting effects. However, consider the following:

• From established reports through HIMSS, consulting firms and industry specialists, a significant number of hospitals (in one report, as high as 90 percent), do not have enough IT in place to meet the requirements for incentive payments. Hospitals/providers will need to meet the “meaningful use” stipulation, which requires the capture of certain data.

• It is more than technology; workflows and operational processes have become a focus in order to improve care and data capture, and different levels of staffing will be needed.

• Will it be the carrot or the stick that provides the incentive to adopt and move forward with the EHR?

One report implies that it will be penalties brought on by Medicare payments versus upfront incentives that will urge the industry to move forward. As stated in the report, “Rock and a Hard Place” from New York-based PriceWaterhouseCoopers: “The American Recovery and Reinvestment Act will reduce Medicare inflationary adjustments starting in 2015 for hospitals and physician group practices that fail to implement a qualifying records system.” The consulting firm estimates that by the time these penalties are fully implemented in 2017, these cuts could cost the average 500-bed hospital as much as $3.2 million a year. Questions that will need to be asked within the organization:

• How does the HITECH Act integrate into the organization's current strategy?

• How does it affect the delivery of care?

• Is delivery of care central to the organization's mission, vision and strategy?

These are all tough questions that need to be viewed, analyzed and acknowledged in relation to current business and IT strategic plans. Adjustments to budgets, priorities, operations and relationships may result from this analysis and regrouping.

The goal of the HITECH Act is to advance the use of health IT without losing sight of the patient and delivery of care, and to advance electronic health records by:

• Requiring government to take a leadership role to develop standards by 2010 that allow for the nationwide electronic exchange and use of health information to improve quality and coordination of care.

• Investing $20 billion in infrastructure and Medicare and Medicaid incentives to encourage doctors and hospitals to use health IT to electronically exchange patients' health information.

• Saving the government $10 billion and generating additional savings throughout the health sector through improvements in quality of care and care coordination, and reductions in medical errors and duplicate care.

• Strengthening Federal privacy and security laws to protect identifiable health information from misuse as the healthcare sector increases use of health IT.

This is all well and good, and three out of the four bullets are clear and attainable. But those who have worked on RHIOs know the challenges of developing regional information exchanges. Developing a nationwide standard and actually exchanging information across organizations is taking an already challenging process and stepping it up a few notches. The Veterans' Administration is still working on standards and processes to effectively do this, and they have been at it for a very long time.

So what about “meaningful use?” Should you wait until it is fully defined? Many healthcare professional, technical, standards and research organizations have come together to provide input and direction on this term and other healthcare standards and policies. One, the Markle Foundation, focuses on the development of policies to help consumers and clinicians improve the health of all citizens, and the health care system that supports them, through the use of IT. Working with other agencies - including the American Academy of Family Physicians, Google, the Joint Commission, McKesson, Microsoft, and the New York-Presbyterian Healthcare System - Markle collaborated on the “Achieving the Health Objectives Under ARRA: A Framework for Meaningful Use and Certified or Qualified EHR” document. It provides a definition of the meaningful use of health IT and encourages innovation in evolving technologies. Essentially “meaningful use” will involve reduction in Medical errors, address prevention and management of chronic disease, outline patient access and attempt to improve care coordination. The above meaningful use matrix can be found at http://healthit.hhs.gov.

The open comment period ended on June 26, 2009, with significant input. However, based upon all articles and indications, we do not expect to see final specifications for “meaningful use” until next year, anticipating in second quarter. The office of the National Coordinator for Health Information Technology is expected to submit a proposed definition before the end of the year, there is a 60-day public comment time frame on this submission. The process then includes another review by the Coordinator and his staff on these prior to making any appropriate changes to the rules; then on to HHS Secretary, who will have to acknowledge and sign off on the final document, however not before the White House Office of Management and Budget reviews the document for financial impacts. Below is a roadmap for the meaningful use criteria.

The battle is on to cut budgets, survive the next few lean months and keep operations going. But what is missing is the solid strategy for organizations and individual providers to capitalize on the HITECH funds that will soon be available. See the charts on page 34 for an idea of what it looks like for providers, as well as the estimated funding available for hospitals.

The hard facts are that you don't just turn on an EHR project overnight. Besides securing resources and planning capital budget expenditures, you have to foster a sense of commitment from your clinical staff. Then you have the issue of securing internal and external resources. Just like the time and funding scale, the longer you wait for the alarm to go off after hitting the snooze button, the less available resources.

Now is the time to layout that foundation. By the time the first payout year hits, most vendor resources and implementation specialists will be fully allocated and you're stuck at the bottom of the “go-live” calendar (and the tail end of the funding allocations).

Those on the tail-end will want to implement a bare bones system. That means they will put in a “shell” EHR without fully integrating with RX, LAB and other ancillary interfaces. This will be a sure fire way to frustrate providers and make them use both an electronic and paper system.

It's clear that the administration wants results and action by the industry with:

• Aggressive timelines

• Incentives kicking in early (beginning in 2010, with the goal for individual EHRs by 2014)

Further, we do know that more structure and detail on definitions, standards, and processes are underway and are expected later this year. We also understand that the incentives will not be sufficient at the current levels for all implementations of the EHR.

There is much work to be accomplished to meet the requirements in the HITECH Act. This includes determining the financial, operational and patient/care delivery, as well as fiduciary effects of the variety of options for implementation. However, it all starts with planning. The HITECH Act provides the opportunity to join together in foundation-laying to improve the healthcare delivery system. Remember the saying, “If you fail to plan, you plan to fail.” Begin the journey; begin to plan as we did earlier this decade with Y2K and HIPAA. Understand the impacts of the Act on the organization - financial, technology, operations and fiduciary. Or hit the snooze button and roll over; other organizations will certainly be waking up early.