One-on-One w/Methodist Health CIO Pam McNutt (I)

As chair of CHIME’s Policy Steering Committee, Pamela McNutt, SVP & CIO, Methodist Health System, is leading that organization’s response to the Meaningful Use Interim Final Rule (IFR). But McNutt’s dual role as member of the AHA IT Policy Advisory Committee gives her an even more powerful vantage from which to formulate a comment, while coordinating the actions of the two organizations. To learn more about her take on Meaningful Use and get a sense of what in that document is most troubling to CIOs, healthsystemCIO.com editor Anthony Guerra recently caught up with this incredibly busy executive.

BOLD STATEMENTS

There’s just no way that everyone can start from scratch, if you consider that your first window of opportunity to prove you’re a meaningful user of a certified system would be Oct. 1 of this year — no one’s going to hit that mark.

… certification is going to include certifying the ability to produce quality metrics out of the system directly. I can tell you there’s no vendor right now that can produce all of those quality metrics.

They’re saying they want CPOE first and bedside medication second, and there’s no particular logic to that, there’s no real logical flow to that decision.

GUERRA: I would imagine you’re working on a comment?

McNUTT: Yes, we are preparing them, and let me say we are aligning closely with some of AHA’s comments, as well as wrapping some of our own around them.

GUERRA: And I see that you’re on the AHA IT Policy Advisory Committee, so that must really facilitate getting those things in line.

McNUTT: Yes, quite a few of us are on both the AHA and CHIME Policy Advisory Committees.

GUERRA: What are your main issues with Meaningful Use, as it’s currently laid out?

McNUTT: Well, first, there’s the eligible provider issue, which looks like it has garnered some attention with legislatures. People are starting to realize that may have the unintended consequence of leaving out a core group of professionals who we want to make sure come up on an electronic ambulatory record. So that’s clearly one.

The other is the whole certification issue and the timing as things are unfolding, or are not unfolding. We were supposed to have some certification regulations about a week ago, so I have real concerns with all the specifications that are going to be required around certification. First we have to get that all laid out, and then will the vendors have enough time to respond to it and have their products certified? There also has to be enough time for providers to implement them.

GUERRA: I know David (Muntz) had mentioned the fact that these large centers, like yours and his, have many, many applications constituting the clinical environment. Those applications are put together in different ways, integrated or interfaced, these types of things. So are we looking at CCHIT site visits as the solution — even though those could be done remotely — but we again come up against the time constraints.

McNUTT: Well, it may not even be CCHIT. They’re only one of the parties, but current CCHIT certification does not qualify.

GUERRA: Well, we don’t know yet, right?

McNUTT: Oh no, we do know. We do know that current CCHIT certification under the proposed rule is not going to be enough. We know you have to be certified under this other criteria. Now, CCHIT clearly wants to be one of those players that certifies, but that’s what we’re waiting for — the specifications of what will be required.

GUERRA: Do you think that a gap certification between a prior CCHIT certified version and whatever the new requirements are will be the best answer?

McNUTT: Well, that’s exactly what we’re making comments on. There’s just no way that everyone can start from scratch, if you consider that your first window of opportunity to prove you’re a meaningful user of a certified system would be Oct. 1 of this year — no one’s going to hit that mark.

GUERRA: The policy makers would argue, “Well, you could still get your full monies if you start in 2013,” but then you’d have to move through Stage 1, 2 and 3 very quickly.

McNUTT: Exactly. We’re certainly pressing that point. They’re going to say, “Well, you can certify in any 90-day period during the first year, so don’t get all hung up on Oct. 1,” but I don’t even see people being ready to go mid-2011, especially if we’re waiting for vendors to have certified products. You may not know this, but certification is going to include certifying the ability to produce quality metrics out of the system directly. I can tell you there’s no vendor right now that can produce all of those quality metrics.

GUERRA: Will you need a site certification to check that all your applications are put together to the government’s satisfaction?

McNUTT: Not necessarily. I’m pretty much going to be able to get certification from Meditech and probably call it a day, because I run everything that I’m going to need for Meaningful Use — with possibly one exception which is transmission of bio-surveillance and public health information; that comes off a system we have called ACE — on Meditech. So by and large, I’ll be able to certify off one system, and a lot of Epic users will be able to do that too.

GUERRA: You have Meditech in the ED as well?

McNUTT: Yes.

GUERRA: That’s usually one place people go best of breed.

McNUTT: No, you’re right, but we don’t.

GUERRA: So there’s a benefit of going with an enterprise vendor that can provide most of your applications.

McNUTT: Oh, absolutely. But we’ll all have challenges, because even if the vendors get their product certified, they’ll have to upgrade many existing customers to that version. Some of those will be major upgrades.

GUERRA: I interviewed Sunny Sanyal who’s the president of McKesson Provider Technologies. He mentioned that McKesson would get all their customers on a certified version of the product, not that they would get all versions in use certified. That’s a big difference.

McNUTT: Well, exactly. With Meditech and many other vendors, we’re hearing that if you go to them and ask for the latest and greatest release, many of them have an 18-month window, even for new clients.

GUERRA: And so that speaks even more to what’s going to have to happen in these health systems, because you may not just be doing new things, you may be doing those new things on a new system.

McNUTT: Training, process-flow changes, absolutely. So you’ve got to do all these and if you haven’t already started doing CPOE, you’re going to throw that on top of the whole thing too.

GUERRA: What’s the situation with CPOE versus CPOE with closed loop medication? Is that being required? I’ve heard with the closed loop is much more intense.

McNUTT: Closed loop medication implies the following; to be truly closed loop, you’re doing CPOE, the physician is entering it directly, a pharmacist is checking it and a pharmacy system is running rules against it, and then the third piece is at the endpoint, at the administration point, you have some kind of bar-coded or absolute check that that drug and that patient and that order all match. There’s three components to closed loop.

Most everybody has the middle component, the pharmacist with a robust system who’s doing checks. Most people have the middle component. And then you probably have a split in the industry of people who thought CPOE was the more important route to go down, and you also had other people like myself who thought that shoring up that final step was more important. So we have bedside medication verification and an EMR up and running, but we don’t have CPOE so, technically, we don’t have closed loop medication administration.

But they did not make closed loop medication a requirement until Stage 2 or Stage 3, even though that’s not absolutely defined. We’re just saying that based on what the Policy Committee put out. They’re saying they want CPOE first and bedside medication second, and there’s no particular logic to that, there’s no real logical flow to that decision. So one thing that the AHA is a proponent of and CHIME is gearing up to support is this notion that these Meaningful Use measures should not be so prescriptive and absolute.

In other words, they are saying, “Here are the 25 things you must do year one.” Well, what if I have been more advanced and more progressive on some fronts? What if I had done bedside medication verification and administration? What if I already have a full PACS system with specialists centrally located that provide the best possible patient care? That’s also required in later phases. But what if I have one of those advanced features right now? As it’s laid out, I get no credit for any advanced feature I may have.

There’s no real literature or anything out there that says you should be doing CPOE before you do PACS. I mean there’s no logical connection between those two, but that’s the way they’ve laid it out. So that’s what we’re protesting. We’re saying, “Why don’t you put a bigger pot of objectives out there and let people pick and choose and say, ‘If you can meet five, 10, 15 of these overall objectives, then you’ve met Meaningful Use, ’” and not tell us which ones we need to do first.

GUERRA: What are the chances that they make that big of a change in the program at this point?

McNUTT: I don’t know. The only alternative is we’re giving them is, “Well, then consider a delay or dropping some of these metrics out totally.”

GUERRA: Well, their response could be, “Nope, we’re going through with this.”

McNUTT: That’s true.

Part II