Much electronic ink has been spilled of late bemoaning the difficult straits of many types of hospitals as the ARRA-HITECH legislation's provisions play out in the healthcare IT industry. Certainly, the requirements involved in hospitals' being able to attest to meaningful use in time to receive the 2011 funding are rigorous and highly challenging. And if CIOs at any type of hospital might be assumed to be worried about meeting those requirements, it would be leaders at the nation's smallest and most rural hospitals (as distinct from hospitals applying for HITECH funding through the Medicaid program, which face an entirely separate set of requirements). But CIOs at many of these hospitals are expressing what might seem like surprising confidence in their progress to date, and are moving forward believing they can do what's needed, in time to receive the first distribution of federal funding in 2011.
Take, for example, Fred Evans, CIO of the 88-bed Hill Country Memorial Health System, an 88-bed hospital in Fredericksburg, in the Hill Country of central Texas. That hospital's board had committed to a vendor in 2004, and hired an interim CIO who brought the system live in October 2005, three months before Evans had joined the staff. After implementing pharmacy, lab and radiology in the initial go-live, Evans helped the hospital go live with nursing documentation in 2007 and with computerized physician order entry (CPOE) and physician documentation in 2008; and with an electronic medication administration record (eMAR) in July of last year.
Still, there have been setbacks. Both nursing documentation and CPOE went live before clinicians were fully ready for those elements, Evans, reports. As a result, nursing documentation was reworked, and went live a second time about a year ago, while CPOE went live for a second time just as this issue was going to press. Evans and his colleagues are also waiting to upgrade to the latest version of their vendor's core EMR product. But they are also persevering and moving forward, requiring all physicians to become proficient in CPOE, and expecting within a couple of months to be totally paperless in clinical operations.
“We fully expect to meet these criteria” under meaningful use, Evans says emphatically, even as he concedes that he and his colleagues have yet to crack the code on meeting the meaningful use requirements for the reporting of quality and outcomes data, particularly the public health reporting requirements. “My biggest uncertainty,” he says, is the “data exchange requirements. I believe we'll be fine with the CPOE requirements by the end of this year.”
Meanwhile, in the small town of Sanford, about 40 miles south of Portland, Maine, Charlie Caruso, CIO and vice president, business process improvement, believes that his organization, the 53-bed Goodall Hospital, will do well in terms of ARRA-HITECH funding, even though he and his colleagues have made the conscious decision not to implement CPOE until the summer of 2011, therefore foregoing the first round of federal funding. “We've purchased CPOE” from their vendor, Caruso says, “but we've had to delay the implementation of both CPOE and eMAR, along with bedside medication verification, because of financial constraints related to the recession; and then our vendor pushed out our start dates.” Nevertheless, Caruso says there might be another way in which he can achieve the CPOE implementation needed to obtain the 2011 funding, if he bypasses his vendor and partially implements CPOE using the hospitalists caring for patients in his hospital. There are in fact a number of gray zones around what “10 percent of orders” actually means, he points out.
Unrealistic or intrepid?
Some industry experts are skeptical that such confidence will be borne out by success in 2011, among them, Jane Metzger, principal researcher in the Waltham, Mass.-based Emerging Practices division of the Falls Church, Va.-based CSC.
“The more you delay in the first stage, the harder it will be to get everything done in time.”
“I think the single biggest challenge boils down to the issue of having so much to do in so little time,” says Metzger. “And even though the new rules decoupled the stages from years, it just means there's a little more room for play in the first part of the meaningful use cycle; but the more you delay in the first stage, the harder it will be to get everything done in time.” The implications for smaller hospitals with fewer resources are immense, Metzger says. “For any hospital that has a fairly good volume of Medicare patients, the penalties can be even higher than the incentives. And so getting things done in time, aside from reputational elements, also has financial implications. And while the influence of Medicare is capped on the incentive side, it's not on the disincentive side.” As a result, she says, CIOs and other hospital executives at smaller hospitals are going to have to very, very carefully assess the financial tradeoffs, given, she notes, that, “Because the incentive is after the fact, where do you get the resources you need upfront?”
The real kicker, Metzger says, is the rigor of the requirements, for smaller hospitals that are unlikely to be close to meeting them, particularly in the data reporting area. “If you delve into the quality reporting,” she notes, “originally, there were to be very few specific measures. Now there are 42 proposed measures for hospitals. And all are required; it's not one of these ‘pick five.’ And in addition to figuring out your performance on these data measures, you're going to have to attest that all your performance data came from the EHR, and that the calculation came from the EHR. The implication,” she says, “is that the amount of structured online documentation required, is significant.” Given all this, Metzger says, she believes the path forward for smaller hospitals without vast resources and years of experience in data collection and reporting will be far harder than the CIOs of those hospitals anticipate.
Deliberate movement in Montana
Interestingly, though one might expect a rushed quality about some of the activity in smaller and rural hospitals, interviewees for this article express almost the opposite. “I need to let you know that we're not going to rush this implementation because of ARRA-HITECH,” says Brian Moreau, senior director, information technology (and de facto CIO) at the 25-bed Marcus Daly Memorial Hospital in tiny Hamilton, about 25 miles south of Missoula, Mt. “There are a lot of hospitals, even in our region, that are going to do that. But this is going to affect us for decades, potentially. So we're not going to rush this implementation and get a poor result.” Most of all, says Moreau, who moved to Montana from Iowa in August 2008 to move Marcus Daly forward in terms of IT, “You especially can't rush the physician elements, particularly around CPOE and e-prescribing, unless you want to fail.”
That having been said, Moreau believes he and his team of six IT professionals can be live with all the core systems by spring of 2011. He concedes that he has a special advantage, since his organization is a critical-access hospital, a designation that changes the math of HITECH. “For critical-access hospitals, the process is more like an accelerated-depreciation schedule on the capital purchases of this technology more than a payment at the end of a Medicare fiscal year,” he notes. And Donja Erdman, the hospital's CFO, adds that, “As a critical-access hospital, we get paid costs based on our Medicare patient mix. And with the electronic health record, we basically depreciate it over three years, so we get the cost of depreciation. Our mix is 50 percent Medicare, so we get 50 percent; and then you get 20 percent on top of that; so we would get 70 percent,” she explains.
Even so, Erdman says, spending $3 million on IT over the next five years-which is what she and Moreau estimate the cost will total-is a hefty sum for a 25-bed hospital. “Healthcare is all about volume,” she notes, “and as a small hospital, you don't have that volume. So it's a challenge in a rural area just to provide basic care, and to recruit and provide the staff to do the job. Fortunately,” she adds, “the critical-access designation definitely helps; and I hope that the policymakers see that and continue to see that.”
Capability gap?
If there's one area that a lot of CIOs and other hospital leaders haven't given much needed thought to, it's in the arena of knowledge- and experienced-based capabilities to handle some of the core data-related challenges under the ARRA-HITECH's meaningful use requirements, say industry experts.
“I think that hospitals have not recognized that they are being tasked with a significant level of upgraded responsibility in the way of data reporting; and they've failed to realize that they're already light on the bench at the outset here,” says Scott Grier, principal of Preferred Healthcare Consulting, a Sarasota, Fla.-based consulting firm. “You can't just take Johnny the Orderly and make him your chief meaningful use officer.” What's more, Grier says, achieving meaningful use is going to require a special kind of team effort, because of the data reporting requirements involved. “To achieve meaningful use, you're going to have to rely on people - clinicians - on whom you haven't had to rely in this way before. For example, if the doctors at your hospital aren't using the meaningful use criteria, then you'll end up collecting a bunch of data that will be useless. But the clinicians will need to be schooled and supported in order to play this game.”
Grier urges CIOs to plan strategically around engaging their clinicians, particularly physicians, early and intensively, in order to make them team players in the efforts ahead. And he especially stresses that CIOs need to keep in mind physicians' special challenge - that they will likely be involved in achieving meaningful use at the practice level at the exact same time.
“I just don't know hospitals will have the money to hire the additional people to accomplish this, to gather, collect, and report data - this is spending money so you can get $11 million from meaningful use that the average hospital might obtain through 2015,” Grier says. “But they've got to find those people in order to be successful in their quest.” The time is absolutely now, he adds, to nail down the human resources, particularly on the clinical informaticist side, that will be required going forward.
Medicaid math
And while Moreau and Erdman have the advantage of their hospital's critical access designation, there is yet another class of smaller and/or rural hospitals working under a different set of rules from the majority; and that is hospitals applying under the separate Medicaid HITECH funding program. One of these is the 49-bed La Rabida Children's Hospital, which serves a socioeconomically challenged community on Chicago's South Side. “We probably won't meet the 2011 requirements, but we'll be pretty close, and we're applying through the Medicaid side,” reports Tim Diamond, La Rabida's CIO. “So we can start going after spending a little earlier. Right now, we just need to prove that we're in the process of implementing things, in order to begin receiving the Medicaid funding. Now, let's say we get the funding, one year from that, I need to have everything in place.” In that way, Diamond says, he believes his hospital will obtain 2011 funding under the Medicaid HITECH program.
In the end, every smaller hospital is different because of its IT implementation history and market situation, says Hill Country Memorial's Evans. Working through one's organization's individual issues is inevitably challenging, but, he says, it would be a mistake to lump all smaller and rural hospitals together under an also-ran banner. Some hospitals will be successful, he's convinced, given the right leadership, effort, and a bit of luck. In the meantime, he stresses to his CIO colleagues, “Don't be bashful about asking for staff, wherever you can get them, because this takes a lot of man-hours, especially in terms of the volume of hours IT staff will spend on training. That's the thing I hadn't quite anticipated,” he says.
Takeaways
Smaller and rural hospitals face particular challenges in terms of matching the needed financial and human resources to the task of achieving meaningful use.
Nonetheless, some smaller and rural hospitals have made surprising progress towards meeting the 2011 meaningful use criteria.
Data reporting requirements under meaningful use will be particularly challenging for this type of hospital; engaging clinicians, especially physicians, in coming together to meet the challenges early on, will be critical to success.
Healthcare Informatics 2010 April;27(4):18-22
