All or Nothing Approach an MU Dealbreaker

An all or nothing approach is the most troublesome aspect of a problematic Meaningful Use NPRM, according to the February healthsystemCIO.com Advisory Panel SnapSurvey®.

“The all or nothing approach not only fails to recognize the progress that so many eligible recipients will make, but could act to discourage others from even trying. The rules should incent,” wrote one panel member.

Forty-four percent of respondents indicated the 100 percent compliance aspect of the proposed regulation cause them the most concern.

Another commented, “Looks like too many directives on the mechanics of demonstrating higher quality at lower cost.”

“I’m concerned that the expectations exceed by a fair shot the reality of possibilities. Perhaps we won’t waste a great deal of the stimulus money simply because most will not have to be paid out,” offered a third.

The second most concerning element of the NPRM was the ineligibility of hospital-based physicians to participate in the stimulus program.

If industry comments, due March 15, have no effect on the regulation writers at HHS/CMS/ONC, Advisory Panel members see trouble ahead. In fact, all respondents thought that less than 50 percent of U.S. hospitals would qualify for Stage 1 incentives by 2013 if no significant changes are made to the NRPN, while 71 percent thought that number would be less than 30 percent.

“In the most recently released survey by AHA, not one of the more than 3,000 hospitals would qualify today. It will be a major effort to meet the requirements as presented. Only if they are relaxed, the number will increase,” wrote one panelist.

Another wrote, though some hospitals are at Stage 1, reporting that fact to adequately satisfy CMS might cause them to be undercounted. “The current statistic on the percentage of hospitals at Stage 1 is about 22. With the MU measurement requirement left as-is, I estimate this statistic to fall lower as the reporting and analytics capability will not be implementable by many organizations by that time. I would realistically estimate around 15 percent.”

“This is difficult to even guess,” wrote another. “This will require not only a significant outlay in capital and operating dollars, but will have a significant impact on processes. Without robust change management principles, the changes required will be short-lived and money wasted.”

Regarding site certification, the Panel yearns for information like the rest of the industry. Over 70 percent said they did not have enough information to know if they will require one, a response which falls right in line with CHIME’s recently release comments on the Meaningful Use NPRM.

“Almost every major facility and most of the smaller facilities are heterogeneous shops. Variety is what helps us reach our goals, but kills our chances to avoid self certification which has yet to be defined,” wrote one panelist.

“This is very much a point of confusion and needs a great deal of clarification. Some say yes, others say no,” wrote another.

“Wish I knew,” responded a third.

Asked, “If you could deliver any message to David Blumenthal, M.D., National Coordinator of HIT, about where the MU bar is being set, it would be the following,” panelists responded:

• I think the focus on safety quality measures should be foremost in Dr B’s mind. CPOE and eMAR should take a priority over electronic patient access at this point. Quality and safety initiatives save lives!
• Stage 1 needs to be within reach of at least 75 percent of the hospitals. More flexibility of the number of measures and outcomes is needed (all or nothing is to stringent)
• He should try to see from the organizations’ perspective — who are really struggling economically — the onerous requirement of deploying the MU’s 28 measures. It is not pragmatic to do this in the time provided. Maybe a shorter set of criteria needs to be thought of.
• Listen and adapt to the messages that the AHA and CHIME are suggesting.
• Their remains a significant gap between the current adoption of HIT and the vision held for transforming the nation’s healthcare delivery system. The bar for 2011 is currently set too high, and the “all or none” approach could result in an inability for smaller provider organizations, where incentives are most needed, to achieve MU.
• 1) Either fully fund this or 2) Slow it way down and go after real reform. Health reform via IT is putting the cart before the horse.
• We need clarification on the role of ONC, CMS and the states on reimbursement mechanism. At the state level, it is not Medicare but Medicaid that is the largest payer.
• Dr. Blumenthal: Have you talked to any CIOs that are not fully deployed on Epic to understand how difficult this may be?
• He has lowered the bar in response to the hospital advocacy and left it too high for physicians. I question the balance of input receive by ONC and HIT Policy Committee. Too much research, not enough community practice?
• The longer we go without finalizing an official certification approach, the more dicey 2011 certification is going to be (and I believe it to be almost prohibitively difficult to establish logistics now).
• This isn’t a positive way to encourage EMR growth. The first step is far too high.
• Come up with a definition for how “orders” are counted for the MU computation that is practical.
• Let us keep it simple and practical. Let us be mindful of unintended consequences of rapid implementation of HIT.
• Many of the requirements seem to be tilted to favor Epic – ie, things that only Epic does out of the box. Could that be because of the bias of the members?
• The timeframes are unrealistic, and you must include hospital-based docs for it to be effective and meaningful
• Please listen carefully to the responders, particularly the large trade associations, AHA, CHIME, HIMSS, MGMA. Their collaborative efforts represent a sincere and practical manner in which to achieve the goals of the Stimulus Plan. We want to provide a pragmatic road map for all to follow. Patients are at the center of everything we do.
• Lofty and laudable as the goals may be, most of us are not in the same place you are.
• 1. Be consistent 2. Set the stage 1 bar lower and see how it shakes out 3. Don’t waste time until July redefining MU
• The timing disconnects with the workforce readiness, certification process and quality metric definitions make it impossible for vendors to get their customers installed/upgraded. It is impossible for providers to meet the requirements in the next few years. Also, define Stage 2 & 3 right now, we need a building-block approach based on the end game.
• We need a simpler, graduated set of criteria.
• The incentive structure is backwards. Rewarding those that have already succeeded, and penalizing smaller and rural providers for not meeting the criteria is a recipe for disaster. Get the funds to the providers that need it the most or you will fail.
• All organizations are not at the same place in their quest for a full blown EMR. Being prescriptive as to what pieces need to be in place and at what time means that only those who planned on the same timeline as the regulations will have a good hope of getting there. Let’s try a different approach that is not prescriptive.
• I think the criteria is worthwhile. However, I think the bar is set too high for some items; i.e. CPOE and medication reconciliation; based on the current state of available technology.
• I suspect we may be creating a train wreck due to the rather fast timeline. Many of the MDs are quite unprepared and relying on the hospitals. The hospitals are trying to get their own act together and the vendors are signing left and right and do not have the depth of experienced staff required.

Responses to the question — “If you could deliver any message to your CEO/CFO about the chances of your organization qualifying for all possible incentive monies, it would be the following” — included:

• Do you have a coin? I could flip it, or we could try one of those magic eight ball devices. In my rate regulated state, it is unclear how the HITECH funds will be distributed.
• Very good chance to reach Stage 1 by the end of FY12. More uncertainty about incremental requirements for Stages 2&3
• Do it, needless of the monetary incentives or the possibility of receiving any grants. Healthcare organizations need to look to technology to wring out costs and assist in business growth.
• We are within range of hitting all of the MU requirements. But closing the remaining gap will require the full engagement of our leadership.
• This is a partial unfunded mandate that won’t do much good for our bottom line and it’s doubtful the money will flow.
• Cautiously optimistic. It all depends on how state decides to allocate incentives.
• Dear Boss,
  What we thought was going to be an attainable target, the Feds have added hurdles to that have put our chances in jeopardy, without adding the value or meeting the previously stated goals for MU to date.
  Sincerely,
  Your CIO (who may get to stay as such in spite of this)
• Yes, we can!
• It will be close.
• We will make 2011, let’s reinvest for 2013 (med device integration, barcode, BI, etc)
• HIEs are a concern, as we will be increasingly dependent on means to move data. Stage 2 is much more daunting than Stage 1, so look ahead.
• I think, overall, we stand a very good chance. Our vulnerability is in not having a robust plan to build HIE with other entities, including patients. Let’s use this as an opportunity to do so now.
• We can do it, but it need your whole support to achieve it
• Without executive champions, the work which must be done will not meet the requirements for stimulus funds. More importantly, we will not be able to achieve the clinical transformation we undertook long before we knew stimulus funds would be available.
• Temper your expectations — We’ve got a lot of work to do, many physicians to get on board, and payments are tied only to Medicare-Medicaid services. (We are in the process of modeling what we think our real possibility may be. It will be less, I am sure, than the “best case” numbers so commonly touted.)
• The incentives are great and if we get something, that is great. We are working on staying away from the penalty.
• We might qualify for Stage 1 in 2012 but are unlikely to get to Stage 2 and 3 based on the recommendations from the ONC Policy and Standards Committees.
• 80 percent chance
• Better make this a TOP priority!!!!
• I’ve already done this. Today, no on can qualify because we have to be using “certified” EMR technology. Certified is yet to be defined, clearly. And who will be doing the certifications are yet to be named. This ball is still in the air. From a systems point of view, we’re close, but the quality measures will be a stretch.
• The amount of money expended will be significantly more than we will receive and will be harder to attain than all the consultants indicate.
• They are all over this and have been. We are Stage 6 today and on our way to Stage 7. Not certain why our peers needed the government to tell them EHRs are the right thing to do. Paper was always a nightmare. As Newt says, “Paper Kills.” Computers can too if not designed, tested, tested, tested and implemented with education and support.