Category Archives: meaningful use

Meaningful Use ‘Malarkey’

While his timing would’ve been a bit off, Joe Biden might have been forgiven if he had smirked and called the October 4th letter asking HHS Secretary Kathleen Sebelius to suspend meaningful use (MU) incentives “malarkey.”  In the letter, four Republican congressmen cite an apparent weakening of thresholds from Stage 1 Proposed to Stage 2 Final Rules as well as a lack of established interoperability standards as contributing to wasted taxpayer dollars.  On the latter point, the congressmen may be a bit premature as Stage 2 appears to advance data and transfer standards such that we may (finally) expect meaningful exchange in the coming years.  On the former point, however, the congressmen might have a legitimate gripe.

The decrease has primarily come during the public comment periods between Proposed and Final rules each time.  As with most legislation, this is presumably due to pressure from large trade organizations (e.g., AMA, AHA and the like) representing their constituents’ concerns.  Regardless of the drivers for decreased thresholds, one thing is certain – while inroads in interoperability are likely in Stage 2, there still needs to be USE of these interoperable EHRs – there must be data to exchange for interoperability to have maximum effect.  This makes the slow march toward 90%+ for certain thresholds a bit curious.  Why would a physician want to enter 60% of medication orders electronically but only 30% of lab or radiology orders electronically.  That’s a hybrid, inefficient workflow.  If you asked physicians which they’d prefer between lower thresholds and hybrid workflows versus efficient systems that help them treat patients, I believe they’d chose the efficient systems.

Ultimately, widespread adoption success will require innovative, disruptive technologies and not just interoperable systems.  Applications and services that change the way we use existing technologies will play a key role.  It’s not enough to make CPOE “better” – better for whom and how is a key consideration.  Traditional desktop CPOE may improve the way a physician places a medication order or they way a lab result is accessed.  Those are examples of individual improvements rather than disruption.  Unifying all patient data and allowing a physician to re-order a lab directly from a result – all from a mobile device while outside of the hospital – is closer to the disruption that’s required.  Simply designing systems that support the way a physician works – non-linear with constant interruptions – is disruptive by healthcare IT standards.

Ultimately, the technologies that break down the silos to create an integrated, physician experience will lead to success – it may even please both sides of congress.  OK, maybe that’s a bit TOO ambitious.

Five HIT Predictions for 2012

One thing you are sure to find this time of year are predictions. I’ve decided to do my own not so much to join the crowd but rather because I look forward to comparing my predictions to what actually happens in a little less than a year from now. So with that, here are my predictions for the year in HIT – which ones do you think will come to pass, and which ones have I missed?

1. mHealth experiences a re-birth

mHealth is all the rage and for good reason – it holds great promise to make a significant impact for both providers and consumers alike. But while mHealth for consumers is still on the upswing of innovation and expectations, mHealth for providers is starting to pass the Peak of Inflated Expectations. Walk the floors of any HIT trade show over the last year+ and you were bound to run into iPads at every turn – not necessarily because these vendors were mobile app developers, but because they either 1) wanted you to think they were or 2) managed to make their products “accessible” via a mobile device. But accessible is not the same as usable or efficient. Perhaps the most public example of this was chronicled in a CIO magazine article that described physicians handing in their iPads after a poor experience accessing their EMR. This doesn’t signify a failure of mHealth for providers, rather it was a failure to recognize that app design is arguably more important on a mobile device than in a portal/web or desktop application. Design flaws and workflow gaps are even more exposed on a mobile device. Now that the market has begun to recognize and experience this reality, intelligently-designed mobile apps (whether native or web apps) will continue to rise to the top and carry providers through to the Slope of Enlightenment.

2. Providers begin to expect full workflow support on mobile devices

This prediction is admittedly a bit late as providers have already moved beyond mobile access to clinical results to expect full workflow support. And why not? We should not expect a physician to access lab results on his/her iPhone only to set that device down on the nursing station next to the computer terminal (that is already in use) to enter orders, document care, enter a charge, etc. Perhaps what has fueled this expectation the most is the iPad and other tablets (though not many others). Not many would expect to enter a clinical note or use order sets on a smartphone, however, the tablet form factor presents a new opportunity to do just that – support a physician’s entire workflow. Full, integrated workflow support is a (perhaps the?) critical component of sustained physician adoption of HIT. Where reasonably-sized form factors are concerned, this will also hold for mobile workflows.

3. What worked for Stage 1 will not for Stage 2

My summary of the first year of Stage 1 Meaningful Use (MU): fewer than expected (or budgeted by OMB) meaningful users in year 1, lots of confusion and less movement due to the Stage 2 delay that wasn’t a delay, and early movers characterized by the use of existing systems to meet the bare minimum Stage 1 objectives (e.g., using ED systems to achieve the 30% CPOE threshold). But many hospital IT and physician leaders have already or will soon realize that a Stage 1 strategy isn’t likely to succeed for Stage 2 and beyond. The latter stages are going to require much deeper adoption, use and exchange of health information. IT leaders will need to lay a strategic path that considers all stages of MU, ICD-10 migration, efficient revenue capture, ACO/Value-Based Purchasing and a litany of federal, state and local priorities if they are to be successful. Each of these and other priorities hinge on efficient, meaningful use (pun intended) of integrated systems that respect and protect physician efficiency (and revenue) if they are to succeed.

4. ICD-10 is not Y2K

As the fireworks exploded in Times Square last night, someone said to me “remember how freaked out everyone was at this very minute back in January 2000?” Yes, I do, and the fallout (or lack thereof) threatens to put providers and hospitals significantly behind the ICD-10 eight-ball if they consider that migration to be another non-event like Y2K. Most reports, surveys and commentary place providers and hospitals significantly behind in their preparations for migration to ICD-10. This will have to change in the coming year. But I believe the challenge and emphasis will ultimately be on documentation and not on systems simply supporting the 4-fold increase in the number and format of ICD-10 codes. IT solutions that focus on improving documentation (thoroughness and efficiency) will best prepare providers for ICD-10 and shield them from the potential loss of revenue.

5. ACOs will (continue) to get more attention than they deserve

This is not a repudiation of ACOs or what they attempt to accomplish. But ACOs have dominated much of the conversation during the latter half of 2011, and I expect that to continue. While the tenets and concepts of ACOs are likely here to stay, I still think it’s too early in that process to warrant the airtime to-date. Instead, providers will continue to focus on many of the critical building blocks required to support successful ACOs in the coming year – they just won’t necessarily be doing so in the name of a formal ACO. Do you sense a common theme? Use of integrated, efficient systems in the name of care coordination and higher-value care. While ACO will undoubtedly continue as the preferred acronym of the day, the foundational work required to support an eventual ACO model will be where the real action happens.

Happy New Year!

What if the question is “What SHOULD I do” rather than “What COULD I do?”

Since it’s signing in February of 2009, the HITECH Act has made providers and hospitals deal with the question of “What Could I Do” with respect to demonstrating Meaningful Use (MU). That is, what systems do we have in place, what systems do we need to acquire/upgrade in preparation, etc. to demonstrate MU? The clock started ticking when Stage 1 objectives were published in the Federal Register, and the clock has been ticking ever since.

But what if you are a provider or hospital living in the rarefied air of asking the question of “What Should I Do?” That is, if you have the infrastructure, systems AND adoption in place and have already collected the necessary 90-days worth of data to successfully attest – SHOULD you go ahead and do so by November 30th (the deadline to attest in Federal Fiscal Year 2011)?

Today’s post by Joseph Conn of Modern Healthcare entitled EHR Early Birds May or May Not Get the Worm essentially points out this question facing certain hospitals as we near the end of FFY 2011. Conn references The Advisory Board Company’s Protima Advani who recommended delaying Stage 1 attestation until FFY 2012.  Advani and Conn nicely described the potential disadvantages of early adoption created by the ONC’s Stage 2 Final Rule timeline – currently anticipated in the summer of 2012 – so I won’t repeat them here.

I agree with Advani, who holds to her original recommendation to sit and wait. Although the HIT Policy Committee has recommended that ONC delay Stage 2 for early attesters (those submitting in FFY 2011), ONC has yet to officially accept this recommendation and change the timeline.

Bottom line, if you are still planning, selecting or implementing HIT, then by all means don’t slow down as you likely still have lots to do. If, however, you have collected the 90-days of MU data and are just waiting to submit, you might as well wait until ONC officially delays Stage 2 or until Nov 30th to make your decision, whichever comes first.

When a Delay is Not a Delay – The Impact on Meaningful Use Stage 2

Much has been made about the Health Information Technology Policy Committee’s (HITPC) recent recommendation to the National Coordinator for Health Information Technology. Their recommendation, described in a presentation on June 8, 2011, was to delay the transition from stage 1 to stage 2 meaningful use requirements by one year. The problem with this recommendation, or more accurately with how it has been reported and interpreted by some, is that it’s only a delay for a relatively narrow group of hospitals, namely those who have or will attest to meaningful use in Federal FFY 2011. As of June 2011, this list included only about 40 hospitals out of 340 total eligible providers and eligible hospitals submitting for reimbursement.

The following table illustrates the impact of the recommended delays for hospitals attesting to meaningful use in FFY 2011:


In short, the timeline for Stage 2 for any hospital whose start year is after FFY 2011 has not changed. It’s only hospitals who decided (and were able) to demonstrate and attest to MU in the first program year that have been given an extra year between stages 1 and 2. The reason – if the Final Rule for Stage 2 isn’t released until Summer 2012 as expected, that would leave these early-adopters (and their vendors) approximately 3 months to plan for and implement the necessary infrastructure, software, training, etc. for Stage 2. That’s obviously an unreasonably short time frame that everyone, including ONC missed.

So what does this mean for hospitals and software vendors? At least three things:

  1. Although the timeline for Stage 2 has only changed for early-adopters, the broader market feels as if they have more time to make strategic and tactical plans for Stage 2, whether that includes purchase, upgrade or something else.
  2. This perceived extra time means they have an opportunity to make a more thoughtful/informed decision that will have a greater likelihood of success.
  3. Waiting on Stage 1 means hospitals actually have LESS not more time to decide on and implement a Stage 2 strategy (early-adopters get the extra year, later adopters will have the same short turnaround). A higher Stage 2 hurdle means it will be even more important that a hospital’s Stage 1 strategy and decisions will help them satisfy Stage 2 as well.

I Will Gladly Pay You Tuesday For A Hamburger Today

It will be three weeks ago tomorrow since CMS and ONC unveiled the Holy Grail of HCIT – the Meaningful Use Final Rule. Why have I waited so long to write about it? Hey, one must savor 864 pages of government-speak every now and again (not counting the comparatively wimpish 228 pages of Standards and Certification Final Rule). True it takes time to go through these with a fine-tooth comb, but one can fairly readily identify the most talked-about pieces of the Final Rule – namely those that tell hospitals and eligible providers what they must do to earn the money. But there have been countless blogs and articles describing the Final Rule – they’ve largely done a fine job with that, and you don’t need yet another one here. I’d rather write about what I think the Final Rule means for HCIT adoption. At least two things stand out to me:

First, there STILL remains a fair amount of important detail left to the imagination, particularly about CPOE, that makes it difficult to predict exactly what it means for HCIT adoption. The Fed clearly lowered the bar across the board by including the Emergency Department and decreasing thresholds for many objectives. But for some objectives (again, CPOE) it’s not exactly clear what the impact will be. CPOE has been made easier (for hospitals AND vendors IMO) by limiting it to medication orders, including the ED and decreasing the threshold to 30% of patients with a medication order. But ONC has created confusion over the issue of who must enter these orders (I mean really enter them). Ironically (perhaps only to me), the Proposed Rule listed RNs by name as being able to potentially enter orders, yet it’s the “by any licensed healthcare professional” in the Final Rule that has everyone scrambling to define whether and which non-physicians must enter orders. Furthermore, by only requiring that ONE medication be entered electronically, has ONC potentially introduced more workflows for providers to navigate – a “compliant workflow” for electronic meds and a “non-compliant” one for paper med orders? That’s not an improvement for efficiency and will only stall physician adoption of CPOE.

Secondly, by introducing the concept of Core and Menu Set Objectives (expected) AND changing so many of the thresholds (expected for some) AND limiting CPOE to medication orders (curve ball) AND bringing the Emergency Department into play (never doubt the power of a good lobby), it’s hard to get a read on what all this really means. And that brings me to this blog post’s mascot – Wimpy. No, I’m not calling the Fed a bunch of wimps – or providers or hospitals for that matter. I will not discount the fact that they still face a daunting challenge to implement, integrate and most importantly use technology that has largely done a poor job at all three.

No, I chose Wimpy because of his famous saying “I will gladly pay you Tuesday for a hamburger today“. Am I saying that the government has created requirements for hospitals and providers for which they will not pay incentives in the future? Some fear just that, but it’s not my point in citing the wise Wimpy. In fact, I’m kind of saying the opposite – we’ll have to wait and see if by giving hospitals and providers a hamburger today whether they will pay us all back (it is the taxpayer’s money after all) with use of systems that will achieve the 5 broad Health Outcome Policy Priorities (remember those?) defined by the Fed way back in February of 2009 when the HITECH Act was created.

So what do I really think? I think the government has provided short-term relief for a long-term challenge. If the lowering of the bar in Stage 1 causes hospitals and providers to just go after Stage 1 incentives and then stop then HITECH will have been a failure. If lowering the bar causes hospitals and providers to lose focus on the longer-term challenge of Stage 2 and beyond, then HITECH will have been a failure. Will it have created jobs in the vendor market? Will it have created a lot of investment and interest in HCIT? Yes to both. But neither of these will satisfy the Health Outcome Policy Priorities of:

  1. Improve quality, safety, efficiency, and reduce health disparities
  2. Engage patients and families
  3. Improve care coordination
  4. Improve population and public health
  5. Ensure adequate privacy and security protections for personal health information

Wimpy, pay up!

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