Meaningful Use: Six Strategic Questions Rural Hospitals Should be Asking

Meaningful Use: Six Strategic Questions Rural Hospitals Should be Asking

Under ARRA, in order for hospitals to access HIT incentives and avoid future penalties they must become “meaningful users” of electronic health records. Now that CMS has issued the final Stage 1 HIT incentive rule, all providers that are intent on participating in the incentive program should be engaged in an EHR planning and implementation process. Here are six key questions to be asking as part of that process:

1. Vendor Certification: Am I hitched to the right horse?

ARRA requires that providers utilize “certified” vendors in order to be considered meaningful users of EHR technology. On August 30^th, 2 organizations (CCHIT and Drummond Group) were selected as the first ONC Authorized Testing and Certifying Bodies (ONC-ATCB).

Providers should be determining whether their partner/prospective vendors have or at least are developing the functionality that will ensure their systems will be certified as “complete” or “modular” EHRs. If “modular” (i.e. only a subset of the applications required to meet all of the Stage 1 meaningful use objectives) providers should clearly understand which modules their vendor won’t be providing and determine whether they can reasonably fill those gaps with other vendors. Vendors that don’t have a clear plan for certification should be treated with skepticism. All contracts with vendors should include certification guarantees.

Vigilant providers will be challenging their vendors to answer detailed questions about how their applications will meet the certification requirements. Questions may include: (1) How does the vendor handle CCR or CCD imports and exports to meet the information exchange requirement? (2) How does the vendor comply with the 9 security standards? (3) What are the vendor’s capabilities to apply point of care decision support toward improving outcomes (particularly for Stroke and VTE patients, who are the focus of the quality submission objective)? (4) How will the vendor meet the medication reconciliation objective by allowing the user to compare two or more medication lists? (5) What is the vendor’s strategy for capturing all of the data elements required for the 15 quality submission metrics?

Just because a vendor is still developing some of these capabilities doesn’t mean that the vendor is unsuitable. However, vendors should at least be able to provide a clear explanation of how they plan to meet each of the requirements they are claiming will be certified.

2. CPOE and Decision Support: Am I positioned for physician engagement?

It’s critical for hospital planners to understand that robust physician utilization of the EHR is the ultimate goal of the incentive program. This being said, Stage 1 meaningful use allows hospitals to utilize RNs and other “licensed professionals” both to perform CPOE and to be the subjects of decision support alerts.

Every hospital planning team should be determining whether it’s reasonable to expect their physicians to directly enter CPOE orders as part of their Stage 1 efforts. Moving to this paradigm optimally positions the organization to meet future meaningful use stages. However, under certain circumstances (including if the hospital is just beginning their EHR journey) it may make more sense to introduce physicians to viewing the EHR in Stage 1 before moving to order and data entry in future stages.

3. How does ED inclusion impact my implementation strategy?

One of the major surprises of the final HIT incentive rule was that CMS significantly expanded the scope of Stage 1 meaningful use by adding ED patients to many of the objectives. While questions remain about the exact scope of the ED requirement, providers should be working on the assumption that they’ll need to implement an ED EHR in order to achieve meaningful use. Providers expecting their HIS vendors to have the required ED offering should be verifying that their vendors are pursuing certification in the ED as well as the inpatient domain. While it may be possible for providers to utilize their certified inpatient systems to meet the ER data capture requirements, there will likely be significant workflow issues associated with this strategy.

4. Am I ready for the QI measure (ER, VTE, and Stroke) data capture load?

According to many commentators, meeting the QI measure objectives will be one of the greatest challenges of the incentive program. There are a large number of data elements that will need to be captured in order for the EHR to make the calculations for the 15 quality measures, and while some of these data elements will be collected as a byproduct of EHR use, others (such as reasons why certain therapies were not prescribed) will likely need to be abstracted from unstructured data sources. This will have a significant impact on QI program workloads. Providers should be assessing what resources they will need to meet this challenge.

5. For CAHs, how will I deal with the eligible EHR cost definition ambiguity?

Critical Access Hospitals (CAHs) will get incentive bonus payments tied to their depreciable costs “necessary for the administration of certified EHRs.” Unfortunately, what exactly constitutes such a depreciable cost has not been clearly defined and may end up being determined by Medicare Administrative Contractors (MACs). This could mean that many CAHs will not definitively know whether their depreciable costs are allowable until after they need to sign contracts with vendors.

In addition to advocating for the greater clarity that’s required if CAHs are to be allowed to engage in effective strategic planning, CAHs must determine how they will invest given this potentially ongoing uncertainty.

6. When should I conduct a comprehensive security risk assessment?

One of the meaningful use objectives is for hospitals and EPs to protect their health information by conducting a formal risk assessment and risk mediation process. Providers may perform this risk assessment even before their meaningful use reporting period begins. Those providers with existing EHRs should consider budgeting for and moving forward with their risk assessments so they have plenty of time to engage in risk remediation activities.

Other questions simmering on the Stage 2 backburner:

7. What is my strategy for evidence-based order sets?

8. Will I need to start coding at the point of care to enable robust decision support?

9. What tools (BI/dashboards) can I implement to manage clinical documentation and decision-making compliance?

10. How will I deal with the workflow issues relating to the summary care record exchange and medication reconciliation requirements (which are currently optional objectives, but which will likely be required in Stage 2)?