Hospitals, let alone eligible providers, seeking to qualify for HITECH incentives have a steep hill to climb, even those with EMRs that are operational or in advanced stages of implementation. Why? One need only look at some recent survey data. On January 4, 2010, Computer Sciences Corporation released the results of a survey of 58 hospitals of their preparedness to meet the criteria for “Meaningful Use”. Here are some of the survey’s key findings.
- Two-thirds of the hospitals have identified gaps in their current EMR systems that inhibit their ability to meet meaningful use requirements; only one-quarter have met at least 70% of the readiness criteria.
- While 70% indicated that their clinical systems were capable of supporting computerized physician order entry, only 8% indicated that they had CPOE throughout the facility with at least 75% of orders personally entered by the physicians themselves, data that correlates with similar surveys conducted by this analyst over the past year.
- While 89% of respondents report on core quality measures, only half capture most required data directly from their EHR.
Surprised? In my view, the CSC findings are far from surprising, but rather reflect some enduring truths that the industry has struggled with for years.
- Physician cooperation and commitment to CPOE is generally mixed, at best, and often absent, particularly in those hospitals that are predominantly a voluntary, rather than an employed, staff model; under this staff model, physician cooperation cannot be mandated.
- Most hospitals are not prepared for the change management process required to effectively and comprehensively implement CPOE and the essential IT governance models that maximize the probability of success are generally absent or immature, at best.
- Computation of many of the core quality measures require data elements that are not routinely captured through the order entry, clinical documentation or results reporting capabilities of many clinical systems; parallel or post-discharge chart abstractions processes must be implemented to capture this data. Such approaches are neither consistent nor compliant with the meaningful use requirements. Continued reliance on such methodologies would not qualify the organization for a HITECH incentive payment.
- Cash-strapped hospitals are often multiple releases behind and cannot afford the cost of upgrading to the most current, fully compliant versions, and it’s highly unlikely that vendors will retrofit ARRA-compliant functionality to older versions.
- Despite all of the publicity, many provider organizations have an incomplete, naïve or incorrect understanding of the specifics and, as the saying goes, “the devil is in the details”.
In my opinion, providers have been waiting since July for the feds to finalize the meaningful use criteria, betting (in vain) that they would “water down” the draft criteria published in July. Not a wise bet, in my view, and a strategy that has now cost many hospitals time that cannot be recovered. Although I believe that the majority of U.S. hospitals are now stepping up the intensity and pace of their planning processes, if they are detailed in the planning and costing, many are likely to realize that the cost of accelerated implementation will exceed the value of the incremental incentive payment they would expect to receive and the non-compliance penalties they will be assessed.
If a hospital has not already procured and is not well on its way to implementing a compliant EHR, the likelihood that they will receive a 100% of the incentive payment they might otherwise be entitled to is, as the expression goes, “slim to none”. Those providers that are “late to the party” should be considering planning scenarios that consider the financial tradeoff between the cost of accelerating their implementations and vs. the revenue impact of penalties for non-compliance. It is likely, in my view, that a sizable proportion of those risk analyses will lead hospital executives to conclude that “haste makes waste” – certainly not the outcome that the feds would like to see, but likely just one of many unintended consequences of HITECH that the feds will have to address in the coming years.
Do you expect that your organization will qualify for a HITECH incentive? If so, when – 2010, 2011, or later? And which criteria will be the most problematic? Let me know your views. I invite readers to post their replies here and to take the meaningful use reader poll at www.systemresearchservices.com.
Anthony Guerra says
thanks for this great post Marc.
The internal hospital politics of this are tricky. For example, the CEO and CFO want the HITECH money, they want the CIO to do whatever he or she has to do to get it.
I don’t see a CIO who says, “We cannot make these timelines” being very popular at the next executive meeting.
Might you have some advice for our CIO readers on how they can make a case for prudence and the loss of HITECH dollars that might entail. I assume if a CIO says, “We can’t make it,” they better be ready with a clear answer to, “Why not?”
Marc Holland says
Anthony, you voice a valid concern. I don’t disagree. The political winds that swirl around many – dare I say most? — hospital CIOs can sometimes make it hard to stand upright. At the risk of belaboring the meteorological metaphor, major IT projects – particularly clinical ones — are all too often a lightning rod for some of the worst instances of political infighting.
I think the expression “you can lead a horse to water, but you can’t make it drink” has some relevance here. While the CIO has the principal responsibility for delivering the selected solution, effectively and on time and on budget, they should be just one of several key participants in the evaluation and selection process — and a lesser player when it comes to deployment. Nursing and the medical staff must play the key roles then. Buying and installing the selected solution is not the end; it’s merely the end of the beginning.
Deployment is the truly hard part, where change management, not technology management, is the critical success factor. I believe that the CIO’s success will ultimately be measured by their ability to convince their C-suite colleagues that a successful EMR deployment – and CPOE, in particular – is dependent on effective change management; technology is simply the platform on which the required organizational, cultural and process changes can be built.
Without these changes, an EMR deployment will rarely, if ever, be successful. Don’t take my word for it; just ask some of the high-profile industry leaders – yes, those with HIMSS Stage 6 and 7 designation. Ask them how long they labored to achieve that status. The lucky ones, perhaps just a few years, but most have been at it, diligently, for far longer. And how long is the HITECH teller window open?
One more point, if I may. I’d like to second the comments made so eloquently by Paul Roemer his post of January 27th. Qualification for an incentive payment is a binary process. Like a circuit wired in series, if just one bulb is defective, the entire string won’t light. Hospitals seeking to receive their piece of the ARRA pie need to be certain that they can jump every hurdle, not just most, or their efforts will be in vain. Achieving most “ain’t gonna cut it”.
And haste can make waste. Shortly after the draft meaningful use criteria were published on July 20th, this analyst was invited to participate in a one-day long HITECH strategy planning session at a large mid-west IDN. This IDN is rolling out Cerner’s latest version across 8 hospitals. IT had concluded that to make the deadline across all 8 would require a significant increase in resources and estimated the capital dollars required. As you can imagine, the amount was substantial.
The IDN’s deputy CFO was also in attendance. His perspective, in light of other committed capital projects and chronic capital constraints, was that further acceleration of the implementation was not only infeasible, but also not cost-effective. Using a discounted cash flow analysis, finance had concluded that foregoing some of the incentive payment and even incurring some of the reimbursement penalties (at least for a limited period of time) would be LESS than the net present value of the incremental capital IT required to meet the HITECH deadlines. Of course, as they say, “your mileage may vary”.
My advice is that provider organizations take a truly objective, dispassionate view of this process and consider all of the risks associated with a hasty decision – and, worse yet — an even hastier implementation. There are not only financial risks involved here, but also the risk of long term organization disruption and discord. Even more importantly, there is a real risk to patient safety. In closing, please forgive me one more historical quote that seems relevant here. It’s from the Supreme Court’s 1954 desegregation ruling, in which they said “with all deliberate speed”. Let’s just hope that widespread EHR deployment doesn’t take quite as long.
Paul Roemer says
Great discussion. To those saying, “Do whatever it takes to get the money,” without having any understanding the cost or the ROI of “whatever it takes.” They are attempting to make a strategic argument—one with two flaws; it is not strategic, and it it not an argument.
The argument fails without even knowing the requirements of Stage 2 & 3. It fails from not knowing what it will take to implement work flow alignment, process redesign, and change management. As I wrote, even for an operator who already implemented EHR and CPOE, they have their work cut out for them to achieve Meaningful Use.
Some of the figures I’ve seen suggest that as much as eighty percent of the cost and effort around having a truly functional EHR come after completing the implementation. I bet the same figure can be applied to the ROI and user acceptance.
The “git ‘er dun” approach will not enable one’s EHR strategy, their HIT strategy, or their business strategy. That approach makes no more business sense than mandating hospitals be painted pink. When complete, the only result is a pink building.
Where a hospital is in its EHR lifecycle should help drive its strategy towards Meaningful Use. Not every organization who tries to meet Meaningful Use will succeed—some will fail due to timing, some due to functionality, and some to acceptance. They will each reap the same amount of incentive money—none.
I just prepared and posted a PowerPoint presentation titled, “Should you try to meet Meaningful Use?” I’d be happy to share the link.
Marc Holland says
Eloquently and appropriately put, Paul. First, I think it’s important for me to explicitly state, for both you and the other readers, that I am a strong proponent of EMR, EHRs, and the expanded use of information technology throughout the care continuum. This investment is not only essential, but long overdue. And I applaud the Obama administration for putting its money where its mouth is, something the Bush administration which, although they can be credited with getting the ball rolling, seemed unable to do. But that said, it’s your tax money and mine that’s at risk here. Personally, I would like to see mine well spent.
Most EMR implementations, (and I am still an adherent of the term EMR when talking about patient records maintained by a single provider entity, rather than an EHR, which I define as a shared record, created by data fed from multiple EMR instances), fail to deliver the benefits anticipated and exceed both timeframe or budget. Why? Most often it’s because the organization failed to commit to the essential workflow and process redesign required before they deployed, the change management to ensure the commitment and support of the affected end user communities or both. This failure is one of the reasons why so much of the total project cost is incurred post-implementation; it simply gets done after the fact, though most often not nearly as well. To fall back on another popular expression, “We don’t have the time to do it right; we only have the time to do it over.”
So what’s likely to happen? At many hospitals, I see several unintended outcomes. Those with more enthusiasm than wisdom will spend money before they understand what they are buying and what they are committing to. I fear the outcome will be, as you phrased it, “some will fail due to timing, some due to functionality, and some to acceptance. They will each reap the same amount of incentive money—none.” I fear that others will just say “the heck with it”, and do nothing, foregoing their incentive money, taking the hit on their reimbursement rates and incurring further organizational dislocation and operational risk by cutting programs and costs to offset the loss in revenue. It’s that same old “bunker mentality” that has characterized hospital strategies for far too long; a management style that exacerbates the two-tiered, “have” and “have not” system of healthcare that this country has endured for too long.
But perhaps the worst case scenario to consider goes something like this. The industry, realizing that it has made an investment in good faith and now will not be reimbursed as expected, will lobby to be paid anyway. They will fan a political backlash in their communities and in their states by crying poverty and claiming that their unreimbursed expenditures coupled with reimbursement penalties will force them into bankruptcy. The industry and the states will lobby Washington and the incentive monies will flow, despite the failure to meet the requirements. Then what? We’ll be left with suboptimal results on an even wider scale. Without any financial incentives to improve the suboptimal results, no one will make the effort to improved the mediocre, baseline implementations; the objectives of meaningful use will never be realized and what we will be left with are broken dreams, a lost opportunity and a costlier, even more inefficient health care delivery system. Perhaps it’s too melodramatic to characterize the Obama policies and the HITECH initiatives as our last, best hope, but it’s the best chance for real improvement that I have seen in my 30 year career. We can’t afford to blow it. Let’s hope we have the time to do it right, because we’re surely not going to get the money to do it over.
Paul Roemer says
I understand and couldn’t agree more with what you wrote. It is refreshing to know that the voices I am hearing need not be my own.
When I try to summarize the issues for my own edification, I always circle back to the same few issues.
• No single person is both responsible and in authority regarding HIT and EHR. Provider-world pauses with each new pronouncement from Washington as though the missing EHR Dead Sea Scrolls had just been discovered in the reflecting pool.
• Those who implemented EHR did so without any idea that rules would be imposed after the fact.
• EHR is expected to serve two business models:
o Washington’s N x M patient/doctor connectivity effort
o A provider’s unique business objectives, none of which have anything to do with a patient in Atlanta being able to connect to a doctor in Anchorage.
• What model would providers be following if there were no Meaningful Use
• If the current EHR national rollout model was any good, providers would be racing to the front of the line to implement EHR instead of having to be offered rebates.
• The national rollout plan lacks viability for several reasons:
o No standards
o HIEs are each being developed in their own vacuum
o A horde of vendors whose mission does not tie to the national rollout or the providers’ business model and who have no incentive to adopt standards
o The requirements and dates for Meaningful Use will probably change once providers have tailored their systems to meet Stage 1
o The requirements for Stages 2 & 3, which may cost providers six zeroes preceded by some number greater than five, don’t exist.
o An ROI can’t be calculated on meeting Meaningful Use
o Both the likelihood and the impact of healthcare reform on HIT and EHR, just got vaguer by some order of magnitude.
I firmly believe the right EHR and CPOE will be great for hospitals. Providers will be better served by finding answers to the question, “What’s in it for me,” rather than, “What do they want me to do?” Unless of course, providers want them running their business.