Hospital Systems Want To Help

Brian Ahier

Brian Ahier

I keep bouncing between cynicism and optimism on ARRA and the meaningful use rule. There are definitely a few problems with the proposed rule but I want to focus right now on how it will define a hospital-based eligible provider. I’m trying to be an optimist, but this portion of the rule really seems counter productive.

Many hospitals would like to help physician practices to adopt and achieve meaningful use of EHR systems. But we will need some clarity on the definition of a hospital-based EP under the proposed MU rule in order to move forward. As written, the rule will consider as outpatient hospital settings those settings that are owned by and integrated both operationally and financially into the entity that owns and operates the inpatient setting. CMS estimates that 12–13% of family practitioners would be considered hospital-based under the proposed definition of hospital-based EP, and therefore would not be eligible for the EHR incentive payments. This will disincentivize adoption for a large swath of providers and really makes little sense.

CDC recently announced this years NAMCS survey. Below are some excerpts from the Federal Register which point towards a logical definition of an eligible provider:

Ambulatory services are rendered in a wide variety of settings, including physician offices and hospital outpatient and emergency departments. The NAMCS target universe consists of all office visits made by ambulatory patients to non-Federal office-based physicians(excluding those in the specialties of anesthesiology, radiology, and pathology) who are engaged in direct patient care.

In 2006, physicians and mid-level providers (i.e., nurse practitioners, physician assistants, and nurse midwives) practicing in community health centers (CHCs) were added to the NAMCS sample, and these data will continue to be collected.

To complement NAMCS data, NCHS initiated the National Hospital Ambulatory Medical Care Survey in 1992 to provide data concerning patient visits to hospital outpatient and emergency departments.

These data were requested by the Office of the National Coordinator for Health Information Technology (ONC), Department of Health and Human Services, to measure progress toward goals for EMR adoption.

Obviously the same providers that are going to be excluded from receiving incentive payments are included in the survey used to measure adoption progress. For consistency, and to truly promote meaningful use, the definition of an EP needs to change. If a hospital system wants to provide a physicians’ EHR and no one is eligible for stimulus funds, then a hospital will make ambulatory EHR a much lower priority, and providers will be forced to go it alone.

It is not to late to do something about this situation. The comment period is open until March 15. Everyone interested in the incentive payment program should comment. If enough comments are submitted on this issue maybe CMS will make some reasonable changes (now many will say I’m much more a dreamer than an optimist) You can submit your comments AT THIS LINK HERE


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  1. Anthony Guerra says:

    Great points Brian. I know this was a big concern on the CHIME Webinar I listened to. I also just read this on HISTalk:

    “Albert Einstein Healthcare gets a mention in the local business journal for its $100 million EMR project. It’s happy about the prospect of ARRA payments, but concerned that only 50 of its 350 owned physicians will be eligible for stimulus money. They say that doesn’t make sense because they use different tools in their practices than they do in the hospital. A Pennsylvania Medical Society spokesperson also expressed concerns about the 80% CPOE requirement for practices, saying that as an example, radiology centers are not covered by the rules and therefore have little incentive to receive electronic orders.”

    It seems like you’ve definitely hit on something.

  2. Another great post Brian. I vacillate between cynicism and cynicism, and find it helpful to toss the occasional metaphorical tomato.

    Here’s an idea I raised a few months ago which I think may tie into the point you raised. What prompted the idea was knowing of a hospital which spent nine figures on their EHR, only to find out that its functionality essentially ended inside its four walls. At the time nobody wrote that it wouldn’t pass muster. This idea may die before anyone finishes reading the comment; if not perhaps it merits at least a look-see.

    From the perspective of the business model of the hospital, what do we know?

    • Hospitals work at attracting and retaining good physicians
    • In many markets, ambulatory physicians may choose to send their patients to any one of a number of hospitals
    • The competition to attract patients and physicians is building
    • The hospital and physicians both benefit if they are:

    o On the same EHR
    o On an EHR which interfaces easily

    What if we change the question being asked, or at least change what constitutes a desirable answer from the perspective of the hospital? Let us go back to what we know.

    • Non-hospital based doctors will not be part of the calculation to determine if the hospital meets Meaningful Use.
    • Each of those doctors benefit from implementing and EHR system, and they will either qualify for stimulus money or be fined.
    • Those same doctors and their patients benefit from having a seamless relationship with a hospital.
    • None of those doctors has anything close to what can be considered an actual IT department.

    o If 400 providers who practice at your hospital have to select an EHR, how many dozens of different EHRs will they select
    o Not only do the providers lack the skills to select a good system, they lack the skills to implement it successfully.
    o Most IPAs are not even offering a recommendation

    What happens if we rephrase the question and ask, “What steps can a hospital take to:”

    • Make ambulatory doctors want to send their patients to them
    • Make it easy for the patient/physician/hospital relationship to appear seamless
    • Possibly be paid for facilitating the EHR for their ambulatory physicians

    If it were my hospital, here’s what I would do:

    • Pull together a plan to figure out how a hospital could offer an EHR solution for each of the ambulatory doctors. This EHR solution could:

    o Be the same EHR or one which can integrate with their EHR
    o Be offered as a managed services solution
    o Be offered as an outsourced solution

    • Figure out what information is needed to determine the viability of offering its ambulatory doctors an EHR solution:

    o Staffing
    o Marketing
    o Incentives
    o Cost
    o Roll-out
    o Training

    • Determine if the ambulatory doctors can somehow sign-over their incentive payments to the hospital.

    o If yes, the incentive payment from 400 ambulatory doctors could fund about $18 million of the roll-out cost
    o If not, there are still a number of great business reasons to think about helping the doctors get on the hospital’s EHR.

    What is the long-term ROI, say five years and beyond, of having an ambulatory doctor send its patients to a given hospital? I bet it exceeds the cost of installing an ambulatory EHR.

  3. Anthony you have uncovered another aspect of this problem: If the ED, Radiology or Pathology is not used to determine the percentage of CPOE orders, then what is the motivation to get these orders entered electronically?
    I understand CMS might be trying to reduce costs by restricting incentive payments, and the initial dollar figures were higher than what they are expecting now, but excluding groups in payments will have the effect of creating serious gaps in adoption.

    Paul also makes a great point! Even without these incentive payments a business case might be made for hospital systems to implement ambulatory EHR with affiliated practices. I’d love to see some hard numbers on long-term ROI of having physician practices send their patients to a given hospital as a result of EHR integration.

  4. consultdoc says:

    Brian, you make a great point. In CMS hasn’t noticed, providers aren’t exactly lining up to jump on the EHR bandwagon. EHR’s today are still in their infancy from a provider’s view point. They still are not seen as a truly viable option by many practicing physicians today. As docs are forced (not led) into EHR use, any barrier to adoption will simply compound an already complex and difficult situation. As we say in the south, your approach of “Y’all come” is not only appropriate, but would send a strong message of inclusion rather than one of governmental definition.

  5. Anthony Guerra says:

    there definitely was a drop in the estimated payouts of the HITECH program. I wonder if someone at OMB got sticker-shock and, now the that initial stimulus spending frenzy has worn off, perhaps they are looking for ways to scale down the program.

  6. lsaldanamd says:

    Great post, Brian. I do think you point out an internal inconsistency here, and as Paul pointed out, not the only one. I do think that we need to be able to stand back from our own preconceived notions based on our own experiences with EHRs, and look at the impact of these rules form the viewpoint of someone coming in at ground zero with the view of what do I have to do to avoid penalties or what do I need to do to get a piece of the pie?

    And I do think Anthony brings up a good point, will the planned payouts get squeezed by other priorities. There is definitely an air of ambient mistrust.

    What will the landscape look like with the rules as they are now? Will we have accomplished what we wanted to and ultimately will we have created value for our patients and for taxpayers?

    I think the interim rule is a good first step, but the concern is will it go directly from first step to final rule without questioning these assumptions.

  7. This is another great thread. I share the concern over the current proposal.

    Ultimately, even if hospitals and offices had the financial resources to navigate MU successfully, I worry that the actual Informatics staff doesn’t exist.

    Brian, your post is excellent at pointing out (as everyone already mentioned) the inconsistencies with MU. I think it’s up to us (as the movers/shakers who weren’t involved in the original discussion) to make sure we use the comment period effectively.

    Thanks for such good writing on the subject! What a beautiful summary of the current state. :)

  8. Jimmy Weeks says:

    If the intent of MU is to promote safe and quality healthcare, then no provider should be excluded.

    Does someone believe placing an order in the ED is any less prone to error than an order place by a PCP in their office? Are Radiology orders so simplistic that handwritten paper orders are acceptable and there is no need to incent for these records and orders to be online? Are patients who visit physicians in a hospital-based outpatient clinic somehow less complex than a patient seen in the ambulatory setting?

    Harm, duplication, errors, illegible and incomplete documentation can occur across all disciplines and service lines. Eliminating any of the team who provide patient care from the MU incentives will prolong the missteps in care and break in communication.

    As consumers of healthcare, we should be provided with consistent safe and quality care no matter what the setting. All disciplines should be offered the same incentives. I guess the question for the people holding the purse strings is how much can they afford to pay vs. how many patients they will place at risk. Inconsistent incentives will results in inconsistent of care.

    I agree with you about staff. We have already heard of the vendors with implementation staff who have no prior knowledge of healthcare, regulations, workflow or systems. They do however have a great smile and are willing to learn, on your dime. Finding seasoned professionals who have several successful implementations under their belt is another story. I know the inbound calling at my shop has gone up in the past year with the unfortunate loss of three good people.

    I’ve also seen more than a few practices make the investment to buy and implement an EMR but not invest in the daily care and feeding any system requires. Applying patches, applying Windows updates, updating anti-virus definitions, making certain the wireless and wired networks are secure, testing their backups, applying strong passwords and all those tasks we in IT perform as often as we breathe.

    It would be tragic for a practice who has highly successful patient outcomes have their credibility and reputation destroyed by data loss or breach. They all need to understand and appreciate the need for continual maintenance of the applications and infrastructure no matter if they perform themselves or outsource. Someone needs to be minding the shop.

  9. Ferdinand Velasco says:

    It appears that reason may prevail as a result of the critical insights that have been shared regarding this topic. From an AHA press release: A jobs bill being drafted by Senate negotiators would clarify the definition of hospital-based physician under the American Recovery and Reinvestment Act’s HITECH provisions to allow physicians who practice in hospital-owned outpatient centers and clinics to qualify for federal payment incentives for health information technology. Don May, AHA vice president of policy, said the association “strongly supports” the provision, which would clarify the ARRA language and ensure that CMS does not inappropriately exclude physicians serving patients in outpatient centers from receiving Medicare and Medicaid HIT incentive payments. The draft bill also would delay through Sept. 30 a 21% Medicare payment cut for physicians and extend premium assistance for COBRA benefits through May 31. Among other provisions, the bill would make a technical correction to reimburse critical access hospitals at 101% of their reasonable costs for Method 2 outpatient services, and extend through 2010 expiring Medicare payment provisions related to rural hospitals, long-term care hospitals, the technical component of certain physician pathology services, mental health services and ambulances.

  10. Unfortunately the provision to extend federal electronic health-record subsidies to so-called “hospital-based physicians” who practice in “outpatient” settings was stripped from the first draft of a Senate Finance Committee jobs bill Thursday by Senate Majority Leader Harry Reid (D-Nev.), just two days after lawmakers first circulated the legislation on Capitol Hill.

  11. Wow, this site is way ahead of the curve…
    Others are now finally reporting that this was stripped from the Senate Finance Committee jobs bill. This web site is becoming a daily check in for me to keep informed!

  12. Anthony Guerra says:

    Thanks Brian – I know there will be a lot of comments urging HHS to make hospital-based physicians eligible. Hopefully they will be considered very seriously.

  13. Well, at least Congress did something useful this week :-)

    The definition of eligible provider has been clarified legislatively regardless of what happens with the rule making process:

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