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.
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!
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.
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:
- 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.
- This perceived extra time means they have an opportunity to make a more thoughtful/informed decision that will have a greater likelihood of success.
- 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.
Many in the healthcare IT industry generally believe that physicians don’t like technology. They cite years of research that shows physicians do not adopt the technology that is ostensibly purchased for them. The research, it turns out, is true – fewer than 10% of hospitals have achieved significant physician adoption of Computerized Physician Order Entry (CPOE), and fewer than 5% have achieved adoption of electronic documentation. Most of the”successful” adoption comes from Academic Medical Centers who employ physicians and residents, and therefore, can control system use to a greater extent. But 90% of US hospitals are community hospitals with largely voluntary staff comprised of independent practitioners – physicians who can and do practice elsewhere including multiple offices and even other hospitals. I would argue these community hospitals are the true test bed for physician adoption of IT.
The notion that physicians don’t use technology simply because they don’t like it is incorrect. Healthcare is replete with examples of physicians incorporating ground-breaking technologies of all kinds into their practice of medicine. From medical devices like implantable defibrillators to the most sophisticated imaging technology, physicians have shown a willingness, indeed a penchant toward adopting technology. These examples are not limited to technologies that involve direct patient care – witness their adoption of smartphones. The number of physicians using smartphones surged to 64% in 2009, and this number is projected to grow to 81% by the year 2012. This adoption rate out-paces that of consumers, among whom 65% are expected to own a smartphone by 2012.
“Usability” is often cited as the main culprit behind meager physician technology adoption statistics. Calls for improved user interfaces and screen layouts often lead to attempts at trying to weave these constructs into EHR certification criteria, for example. Indeed, the talk in the industry of late is around trying to impart usability as a requirement of Meaningful Use certification. As with prior attempts to legislate usability, however, these efforts are largely doomed to fail as the color, size and location of a button or a screen is not the primary culprit behind historically poor physician adoption.
The primary reasons for poor adoption have more to do with utility than usability. Simply put, if the technology is of no real benefit (or worse a detriment) to the physician and their practice of medicine, they will not use it. CPOE is the poster child for this challenge. Since before the Institute of Medicine’s landmark 1999 study “To Err is Human,” the industry has tapped technology, namely CPOE, as the keystone for reducing medical errors. Despite broad agreement on this as a chief benefit of CPOE, physicians have shown no real inclination to use these systems. Do physicians not believe in reducing or avoiding medical errors? Of course not. Instead, physicians struggle with systems that do not support their logical workflow and require them to provide information and respond to alerts that are better suited to other clinicians such as nurses, pharmacologists, radiologists, etc. These systems consume additional time on their busy schedules – time they cannot spare (a 10% reduction in physician productivity results in a 20% reduction in revenue).
Ask yourself, would you use something that provided no direct benefit to your daily work, or worse, provided no benefit AND took more of your time? What if that “something” wasn’t even designed for your use, would you use it then? That’s essentially what we are asking physicians to do – use technology that wasn’t designed for their benefit, but we feel is worthwhile nonetheless.
You say physicians don’t like technology? I say they don’t like technology that does not benefit their practice of medicine.