One-on-One with Jane Metzger, Principal Researcher, Emerging Practices, CSC Corporation

Jane Metzger, one of the leaders in the Waltham, Mass.-based Emerging Practices group at the Falls Church, Va.-based CSC Corporation, recently co-authored a report entitled, “Meaningful Use for Hospitals: The Top Ten Challenges,” with colleagues Erica Drazen and Beverly Bell. The report offers insights on the areas CIOs and other hospital leaders should focus on as they pursue federal funding under ARRA-HITECH, and contains a chart of the draft requirements for meaningful use for 2011, 2013, and 2015 highlighting how rigorous those requirements will be. Metzger recently spoke with Contributing Editor Mark Hagland about the report and the journey towards meaningful use certification.

Mark Hagland: There is a great deal of helpful information in your most recent report. The chart alone is quite fascinating.

Jane Metzger: Yes, people should really look at the chart. And people are focusing on CPOE and clinical documentation, so really, people are focusing on the big applications. And as we know, most hospitals and physician practices have a long way to go. But really, there are some other pieces of meaningful use that are very significant, one of them being the data analytics that you need, which of course means structured data, which implies some kind of capability to do fairly sophisticated data analysis. And I think the other piece that isn’t being focused on as much is the information exchange with patients. That’s one of the big, perhaps unexpected, parts of meaningful use for the hospital. Up until now, we’ve tended to think about PHRs and things like that, attached to physician practices. So I think that’s the second contribution of this paper, both through the chart, and through the calling-out of those other challenges.

Hagland: Everyone is focused on 2011; but the ramp-up required of hospital organizations in the four years following that year is very fast and very vigorous.

Metzger: That’s right, everyone is focused on 2011; but 2013 involves big increments of change. And to be ready for 2011, you need to be ready by the end of 2010. Now, you have three years to 2013 if you start today, but still, I agree with you, it’s a lot.

Hagland: Is there any justification for not moving forward now to implement the requirements under meaningful use, as they now stand?

Metzger: Well, I think that history always shows us that when CMS does something, the other payers follow. So I think it’s quite reasonable to expect that other payers may not ante up the incentive; but I bet they will get on board with the disincentives. And I think with such a large-scale, highly visible, national program, it will be difficult for hospitals to opt out, especially given the financial incentives involved. While those incentives may not cover the whole cost, we’ve been hearing from providers for years that cost was probably the single largest barrier; and now there are financial incentives. And even that involves support after the fact, you’re not going to get paid for your intentions, you’re going to get paid for your accomplishments. This whole program sort of eliminates at least the magnitude of that barrier.

Hagland: What is your sense of how academic medical centers are doing in terms of satisfying the meaningful use requirements? Are most fairly far along?

Metzger: There’s probably no academic medical center that’s 100 percent there today; there are a lot of nuances in the requirements.

Hagland: And for smaller or mid-sized community hospitals, how big a challenge is this right now?

Metzger: It’s a fairly big challenge, because the smaller and mid-sized community hospitals have small IT shops; and though they might have some hospitalists, they’re more likely to be managed by community physicians who are not employed by the hospital. And whenever you talk about new computer use for nurses, you’re talking about the single largest labor pool in the hospital. It’s definitely a big challenge for the average-sized community hospital. And given the requirements involved in achieving meaningful use, it’s not reasonable to think that the pace and scale of implementation required are going to be easily accomplished using existing resources.

There are a few major thoughts I would mention here. First, because of the changes involved, moving forward will really require big-time change management, to succeed. Second, these changes will involve really every clinician who touches inpatients. What’s more, the [federal authorities] at not looking just at the “meaningful” part of the requirements under the HITECH funding rules; they’re really looking for evidence that the EHR is being used as a platform for some pretty serious work to improve clinical practice, patient safety, quality, and efficiency. So it’s way more than just getting clinicians to touch the keyboard. So, you have to get involved in change management, because you’re radically going to change the work of every clinician who touches an inpatient; and finally, you’re going to have to really demonstrate that this will lead to serious, and then ultimately successful, improvement, in quality and safety. And you can infer from all the “TBDs” [in the requirements, as set out in draft form at the moment], that there are going to be more outcomes measures.

Hagland: What is the bottom line for CIOs in all this?

Metzger: For CIOs, I think that the concept that an EHR is not an IT project is pretty well understood today. The CIO is certainly going to be part of this. But the only way that hospitals are going to get there is if really the whole executive team and the clinical leadership are leading the charge.

Hagland: What percentage of hospitals will be successful in this?

Metzger: We can’t be certain what is ultimately going to come out in terms of the final-final requirements, but my suspicion is that the list is going to look quite a bit like it already does. Also, we’ll know more later about measures, and the measurement process. But I would think that, for many hospitals, meeting that first level of meaningful use isn’t going to happen until 2012, because if you look at all the stats on adoption, the 14 percent using CPOE and those kinds of statistics that keep coming out, for many of those that are not part of that 14 percent, it may turn out that 2012 a more reasonable stretch goal.

Hagland: But if they don’t meet the 2011 requirements on time, they might also not meet the 2013 requirements in time?

Metzger: Yes, that’s one of the challenges, because one of the reasons you need to get to 2011 is not just to get your incentive, but because you really need to clear the decks in order to get to the 2013 targets. So it will be a sprint throughout; and obviously, hospitals will have to have a strategy, and if they move things back by one year, it may make even the second step of the sprint even harder. And if you look at the chart, it doesn’t add as much of a set of leaps to 2015 as to 2011 and 2013, as so far specified. So even the ones that are part of the 86 percent as opposed to part of the 14 percent, if you look as far out as 2015, that’s five years. Given what needs to be accomplished, that’s not a lot of time.