In my last posting, I talked about some of the Meaningful Use observations made at the recent Health Stimulus Exchange Conference in Boston. Another interesting factoid cited at the conference came from Mickey Tripathi, in his presentation on Regional Extension Centers. Mr. Tripathi, who is the co-chair of the Information Exchange Workgroup of the HIT Policy Committee, cited data from a presentation given at the HITPC meeting held in Washington on December 15, 2009. The presentation drew upon data originally developed for a paper entitled: “The Development of a Highly Constrained Health Level 7 Implementation Guide to Facilitate Electronic Laboratory Reporting to Ambulatory Electronic Health Record Systems”, published in the Journal of the American Medical Informatics Association in February 2009. It eloquently makes the case for constrained, and therefore more “standardized”, standards. For readers interested in reviewing the paper, it can be found at:
http://jamia.bmj.com/content/16/3/285.full
The authors of this study included Dr. Marc Overhage, of the Regenstrief Institute and CEO of the Indiana Health Information Exchange (IHIE), arguably one of the most highly respected and mature HIEs in the country, and Jonah Frolich of the California Healthcare Foundation, who is also a member of the IEW.
The essence of Mr. Tripathi’s comment was that achieving Meaningful Use for tens of thousands of private practitioners, even those that have already implemented EMRs, will not come easily. As an example, he cited the complexities the industry faces in complying with just one of the stage 1 Meaningful Use criteria. It’s the one which states that in order for the provider to qualify for a HITECH incentive payment, “at least 50% of their patients’ lab results must be recorded electronically in the provider’s EMR as structured data.” The operative words here are “structured data” – PDFs, digitized fax images or any other form of “e-blob” won’t cut it. Now keep in mind that qualifying for a HITECH incentive is a binary process. Unless CMS relaxes its requirements when the IFR is issued this spring, a provider must meet 100% of the requirements or it will be “close but no cigar”.
Consider these facts and draw your own conclusions. The clinical laboratory service provider market is, in vast areas of the country, a cottage industry. 75% of laboratory tests ordered by private practice physicians are performed in either small, local commercial laboratories or the local community hospitals where these physicians have attending privileges, with only 25% performed in large regional or national laboratories. Furthermore, most physician offices, regardless of size, have relationships with two or more laboratory service providers. Are you getting the picture?
While laboratory orders and results were among the first transactions to be standardized under HL-7, the format specifications are so broad, and so customizable, as to virtually constitute no standard at all. And there are, literally, hundreds of different lab tests and hundreds of different result message formats. Hospitals and commercial labs, if they have automated results reporting at all, have implemented a wide variety of formats, even for the same test types.
Now let’s do some quick “back of the envelope” calculations using a hypothetical, but realistic, example. Anytown General Hospital is a 150-bed community hospital, the only hospital in a town and the primary laboratory service provider for the 100 physicians practicing in the community. They perform routine clinical pathology – Chemistry and Hematology — and Microbiology services. They log and accession but send out the more sophisticated testing to multiple specialty labs. They currently fax all internal and reference lab test results back to the ordering physicians’ offices. Let’s assume that, if implemented electronically, AGH’s profile of internal and external lab services would require the implementation of 20 different electronic reporting formats – probably a conservative number.
AGH has the XYZ LIS installed. It’s been in place for 10 years. Maybe it’s not the vendor’s current release. Maybe it’s not even the vendor’s current product – potentially a further complication with significant cost implications to AGH. Let’s assume that the vendor (or an external consultant) will charge $5,000 to develop and install each interface.
Looking to take advantage of the HITECH incentive program, the hundred physicians in town all buy an EMR, but can’t reach a consensus purchasing decision. Collectively, their choices represent 20 different products. Do the math. Let’s see, how many unique outbound HL-7 result formats does AGH have to send? Um, let’s see: 20 x 20 = 400. And the cost? Um, let’s see: 400 x $5,000 = $2 million. Further, suppose AGH or one of the commercial labs is running an older unsupported LIS and the vendor refuses, requiring them to upgrade to the current product. What incentive is there to justify that expense?
So let’s summarize: thousands of hospitals, along with thousands of private commercial laboratories, could (conceivably) have to develop (or pay their LIS vendors to develop) thousands of interfaces at the cost of – dare we say it – billions of dollars. I’m reminded of the famous quote by the late Senator Everett Dirksen, the senate minority leader under President Lyndon Johnson, who was credited with saying: “A billion here, a billion there, and pretty soon we’re talking about real money.” If you don’t agree with my numbers, get your own envelope and see if the result is materially different.
So who pays? I’m not sure, but someone has to cover the cost. But no matter who does, it’s sure going to cut into the incentive payments hospitals and physicians expect to receive. And mind you, this cautionary tale is based on the impact of just one stage 1 criteria. Remember, it’s expected that stage 2 Meaningful Use criteria will require providers to also transmit orders electronically. How many additional interfaces could that require AGH to implement?
Look for provider CFOs and consultants alike to be promoting much more detailed financial analyses than this one as the HITECH euphoria fades and harsh reality set in. I’m afraid that many organizations will decline to make the investment, choosing instead to “take their lumps” in the form of reimbursement penalties and, by extension, jeopardize their trading partners’ ability to qualify for an incentive. Can you say “unintended consequences”?
The evidence makes an eloquent case for the adoption of meaningful standards; standards so “standard” that integration is simplified and cost-effective. After all, wasn’t that the original intent?
Anthony Guerra says
Marc – thanks for this excellent post. You paint a grim portrait, but one that needs to be painted. I recently listened to a Standards Committee meeting that seemed to end with more questions than when it started. https://healthsystemcio.com/2010/02/25/standards-committee-struggles-for-balance/
There is so much work to do and absolutely no time to do it. There is too much being asked of too many with insufficient time (and money) to complete the tasks.
Shahid N. Shah says
Very nice posting, Marc. It is so much more useful to show real numbers and not vague hand waving. The evidence, while high level, is compelling indeed. Since I’m from DC I’ve been to many of the ONC commitee meetings (those open to the public) and I’ve never hear anyone talk about the cost to implement any single MU item much less all the MU items. Scary stuff.
Marc Holland says
Shahid — actually, the basis of my post came from information that was discussed at the HITPC meeting in DC is December. It was presented by Mickey Tripathi of the Mass e-Health Collaborative. While Mickey’s testimony did not cite the specific cost implications, it should be considered part of the growing wave of concern being voiced throughout the industry with respect to the implications of compliance. The blogs from other contributors here, and those that have commented,highlight the debate as to the likelihood and the importance of relaxing some (many) of the draft criteria. Given the magnitude of the concerns, I suspect that some relaxation is a strong possibility, though far from a certainty. That said, I still advocate that providers, both big and small alike, conduct a careful, objective and quantitative analysis of the costs and benefits of compliance.
Also, I want to add that CCD-based interfaces (if feasible for a specific provider’s circumstances) could serve to mitigate some of the costs I projected — yet another reason for a careful, studied approach.
Shahid N. Shah says
Great points, Marc. Thanks for the note.