As the comment period has closed on both the Meaningful Use NPRM and Certification Standards IFR, the industry takes a collective deep breath in anticipation of the final rules. CIOs like Buddy Hickman (also an executive vice president) have thought hard about the proposals and given their feedback through industry organizations like CHIME and HIMSS. One concern of Hickman’s is the “denominator problem” — accounting for every single order processed in a hospital as the universe against which to overlay the electronic ones. To learn more about this issue and others, healthsystemCIO.com Anthony Guerra recently caught up with the New York-based CIO.
BOLD STATEMENTS
I’m hopeful that, as we move toward the final rule, there may be some stepping back on the non-EHR related requirements.
… we still all have to work through the issues internally as to priority for capital and resources because this isn’t the only thing going on.
… there are few things you can look in there and say, “This seems superfluous, how did that sneak its way in?”
GUERRA: What are your overall thoughts on where the bar has been set regarding Meaningful Use?
HICKMAN: Clearly, meaningful use is about creating clinician adoption of electronic health record tools, and when I say tools that also has certain extensions. I think the intentions are right. I believe that many healthcare provider organizations are already on the path to what the HITECH legislation intends. The difference now is that we have the government writing requirements for us.
It used to be that each individual entity was finding its own way, which meant you could do things at your own pace. You certainly were looking at this as an investment amongst many different kind of investments and resources — whether its capital, people or otherwise — and going through an annual process to validate that you’re on the right track. The working teams were having appropriate internal intellectual debates about what comes first in terms of functionality or content or applications. And so I think there was, in most cases, a fair degree of independence in terms of how providers were approaching the process of putting electronic health record in.
Again, the difference now is if you want to see incentive money, certainly if you want to avoid penalties, you’ve got to be concerned with hitting specific requirements in certain timeframes and across stages. That seems to be the new thing that has so many of us energized. I’m hopeful that, as we move toward the final rule, there may be some stepping back on the non-EHR related requirements — there’s a couple of them out there; for example, electronic claim submission and referral eligibility management are two that are not what I would call EHR-centric, but probably more revenue-cycle centric. It would be nice to see us step away from those, as far as how the feds end up ruling, and keep the energy around electronic health record items. And with that I’d say they should maybe even add a few more nuances.
For example, I know some parties are talking about the potential addition of nursing documentation elements or the electronic medication administration record. Those are features typically that are going to come along with meaningful adoption, and so they should be considered a part of what we’re trying to put together here.
I’m also curious as to see how the feds resolve the debate of where the bar is being set. My take is that we’ve got a few providers — and by that I mean maybe 15% or less — who are very, very close to being positioned for Stage 1, and even directionally for Stage 2. I believe those organizations will fair well as we move through the final announcement. Everybody will have some work to do because there are certain things included here that nobody anticipated, but there’ll be a small minority population that will be well-suited.
On the other hand, I was looking at some HIMSS Analytics data just a couple of weeks back and if I understood the data correctly, I think there’s about 20% of the provider community in the country who aren’t even at what HIMSS Analytics will characterize as Level 2 adoption, which requires having some very rudimentary things in place like a repository and three specific ancillary feeds. If you’ve got hospital organizations still in that disposition, they’re going to have a very tough time meeting the timelines to see any incentives. They may still have time to beat the penalties, but there’s not necessarily an upside for them.
And in the end, incentives or not, we still all have to work through the issues internally as to priority for capital and resources because this isn’t the only thing going on. And you lay this up against the potential for healthcare reform, or once again healthcare financing reform, and we’ve got to stay watchful to get through this.
GUERRA: So you are looking for some adjustments in the criteria, not necessarily the bar being lowered?
HICKMAN: Maybe it’s better to think of hurdles. It’s harder to run a track and jump the hurdles when the hurdles are close together. And so perhaps we need a little bit more of a running start and a little more distance between the stages, and then things would play out fine. I wouldn’t say there are flaws, but there are few things you can look in there and say, “This seems superfluous, how did that sneak its way in?” That doesn’t create big, big issues or problems, but it would be nice to see the staging spaced out a bit more, and I do expect a few things will be withdrawn from the table.
GUERRA: You said that there was a few things included that nobody anticipated. What are those?
HICKMAN: Let me phrase it differently. I wouldn’t say that they weren’t necessarily anticipated, as much as I use the term ‘snuck in.’ If you look at the requirement around, for instance, recording chart changes and vital signs — height, weight, blood pressure, calculate display BMI, plot display growth charts for children 2 to 20 years of age including BMI. That’s under the Stage 1 criteria. There’s a question as to how relevant, for instance, a growth chart is on all peds all the way to 20 years of age. And I guess there’s a thought process that says perhaps pediatrics become adults when they go to college, and then they might be swapping over care from peds to an adult physician, but there’s no hard and fast rule around that.
And so this question says, “Why are we doing growth charts in regulatory form from 2 to 20?” I’m not sure about that. The clinicians I sat with weren’t quite sure about that. It’s not like these things are difficult to spot to those that are close to the work, and I know these are the kinds of things that are being lifted up to be talked about as potentially being altered.
GUERRA: So if an item has an administrative burden with it, but no obvious upside, you’re going to question it.
HICKMAN: Sure. And there are number of these things that are continually being discussed. I can’t tell you the number of calls I’ve sat on where folks say, “Okay, we’re supposed to hit a utilization percentage of all orders with CPOE whether it’s the 80% hurdle for the practice or the 10% hurdle for the hospital.” The question I hear people continually asking is, “Well, how do we know what the denominator is?” Because there are certainly a lot of manual things written. There can be different classifications as to how those are handled within the organization. I mean there are medication orders, but the way you treat most medication orders versus a very sophisticated, let’s say nuclear isotopic IV drug admixture, are two very different forms.
I’m going to back up a second here. Let’s just say imagine comparing the billing of a standard generic prescription drug for administration orally X number of times a day at such and such dosage, as compared to writing a nuclear isotopic admixture for chemotherapy purposes where different agents have to be rendered and mixed under a hood and so on. Well, the way those orders get written are different activities by physicians, sometimes involving a physician sitting down and doing something computational on paper and providing that with the order to the pharmacist who’s going to do the admixture; and that’s the way it gets reviewed. Well, now as all of that gets turned into structured data and typed into a computer versus someone sitting down and building it otherwise. It could take a lot more time for the clinician to sit and deal with trying to create that in a computer system versus handwriting it. In this case, handwriting may not necessarily be dangerous.
So how do you account for all those orders in the denominator? We’re not sure; we’re not sure how easy it is to substitute and get adoption to occur for those kinds of forms. So I think that’s another item that people are talking about when they question the denominator. That’s one example of why this is problematic.
GUERRA: It would seem to me that there is no possible way the regulation can address every scenario, so sometimes you will be flying blind.
HICKMAN: I think the way most providers are addressing this is via participation in all sorts of advocacy groups that are capturing feedback and assuring that feedback finds its way into the open comment registry at CMS. I know my dialogues with HHS usually end with: “Those are thoughtful things, I can’t necessarily respond to you directly right now based on where we’re at in process, but I want to encourage you that you go out and register your comment so that we have it captured because they are being reviewed.”
This is how a lot of us are spending some of our time right now. CHIME, HIMSS, AHIMA, AMIA — to name a few of the professional associations — all have advocacy teams for the sake of providing comment. Our vendors also, in some cases, have advocacy teams and special government ad hoc groups that are capturing inputs from people that are doing this work.
I’m probably just scratching the tip of the iceberg here, in the sense of how much activity is going on. It’s not that we’re sitting around reading this stuff and wondering what legal positions we’re going to take on it, as much as sitting down and having practical conversations about what we can do to make this work, what makes sense, and what means are out there for us to provide our voice.
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