Meaningful Use in 2010: Summary of Key Events
What a year! 2010 began with the big bang of the release of the proposed HIT Incentive Rule. Now, after a year of intense dialogue, final rulings, certification activities, and continued plain-old EHR implementation work, we’re only a few months away from the first providers receiving Year 1 incentives. Here’s a recap of some of the year’s key events and issues that are impacting rural hospitals.
Final HIT Incentive Rule:
The Final HIT Incentive Rule took the edge off of what was a heavily criticized NPRM. By providing a modicum of flexibility through a menu option, by redefining “Acute Care Hospital” to include CAHs, and by removing the requirement that CPOE orders be directly entered by the ordering physician, the Final Rule was enough of a compromise to gain wide acceptance among the healthcare association community. However, many of us continue to have serious concerns that the program’s one-size-fits-all large hospital framework and the overly aggressive timelines make achieving meaningful use (and thus receiving incentives) a serious uphill challenge for the smallest and most disadvantaged providers.
Associated previous posts:
Link to “Final Stage 1 Meaningful Use Objectives”
Possession of Menu Requirements FAQ:
Soon after the Final Rule was released, CMS and ONC began to issue clarifications through the FAQ response process. One FAQ response (CMS FAQ 10162) required that providers “possess” the technology to meet all of the “menu” objectives even if the provider intended to defer some of those objectives into future years. The AHA rightly spoke out against this; then another FAQ was issued (ONC FAQ 21) through which ONC seems to have created a concept of “possession without ownership.” As if things weren’t complicated enough, providers must now worry about negotiating agreements to possess the deferred menu portion of a vendor’s software while not paying for it until some future date when the capability is utilized. The agencies should have just caved on this one! It makes no sense to require possession prior to utilization.
I’m pasting in the relevant language from FAQ 21 directly below:
“While we recognize that eligible health care providers may enter into various business arrangements depending on their particular needs and circumstances, we would expect that such arrangements could potentially include agreements with EHR technology developer(s) to access and use the capabilities included in Certified EHR Technology. Further, that these business arrangements could make an eligible health care provider’s payment for a particular capability contingent on its use or implementation of that capability in a production environment or the provider’s request for maintenance or technical support.”
Who Can Enter CPOE Orders FAQ:
Perhaps the most worrying, if largely unnoticed, FAQ tussle occurred over the issue of who can enter CPOE orders. The final rule clearly indicates that CPOE orders can be entered by other “licensed professionals” on behalf of the ordering physician. But CMS FAQ 10134 introduced the concept of “originate,” at least arguably implying that the ordering physician was responsible for direct entry. After several weeks, the FAQ was revised; the word “originate” was replaced with “enter”; and we’re back to the final rule’s clear (and appropriate) intent that any licensed healthcare professional—assuming they are capable of making clinical judgments in case the entry generates alerts—may enter the CPOE order for the ordering physician.
I’m pasting in the relevant language from CMS FAQ 10134 directly below:
“Any licensed healthcare professional can enter orders into the medical record for purposes of including the order in the numerator for the measure of the CPOE objective if they can enter the order per state, local, and professional guidelines. The order must be entered by someone who could exercise clinical judgment in the case that the entry generates any alerts about possible interactions or other clinical decision support aides. This necessitates that CPOE occurs when the order first becomes part of the patient’s medical record and before any action can be taken on the order. Each provider will have to evaluate on a case-by-case basis whether a given situation is entered according to state, local, and professional guidelines, allows for clinical judgment before the medication is given, and is the first time the order becomes part of the patient’s medical record.”
Associated previous posts:
Link to “Who Can Enter CPOE Orders.”
ED Inclusion Methodology FAQ:
Another important FAQ response created much-appreciated flexibility for how hospitals may deal with the Final Rule’s surprise inclusion of ED patients. By creating two distinctive methods for counting ED patients, the “All ED Visits” or the “Observation Services” methods, CMS tacitly acknowledged that hospitals should have discretion over how to prioritize their respective ED and inpatient EHR implementation work.
Associated previous posts:
Link to “Two Options for Counting ED Patients”
What Qualifies As CAH Expense?
Ding Ding Ding: the number one question from CAH administrators is what costs qualify for the CAH Medicare Incentive. This question has been posed to CMS in several forms (including in one of my previous blog posts), but CMS has been unwilling to step up to the plate and further define what is a highly ambiguous definition of qualifying costs: “costs incurred for the purchase of depreciable assets … such as computers and associated hardware and software, necessary to administer certified EHR technology.”
Unless an FAQ response is forthcoming, it appears that MACs will become after-the-fact arbiters of what qualifies. This is a major problem, since not knowing what qualifies as an eligible cost makes it tough for CAHs to plan strategically, and is preventing some from getting loans.
Legislators would be wise to revise what is a badly designed CAH incentive structure (contingent on undefined costs) with one that mirrors the “subsection d” (PPS) hospital incentive structure (a fixed bonus amount).
Associated previous posts:
Link to “What Qualifies for the CAH Incentive?“
Vendor Certification and Challenges:
One early 2010 concern—how quickly vendors would get certified by ONC-ATCB certifying bodies—has largely evaporated. With four certifying bodies now in place, and nearly all of the commonly used HIS vendors (both large hospital and community hospital) certified, the question has shifted to how quickly vendors can schedule new implementations and upgrades to their certified releases. The answer in some cases is “years.” So every provider should be making sure they are in their vendor’s queue for whatever upgrades will be required to meet the meaningful use requirements.
Wisconsin REC Work Underway:
Regional Extension Centers were established to provide technical assistance to prioritized EPs (through the regular program) and to small hospitals (through a supplemental program). Just this week, ONC announced an expansion to the supplemental program that will increase funding and provide an additional 2 years to do the work. This is great news! However, it should be noted that RECs aren’t obligated to use the rural hospital funds to actually help rural hospitals achieve “hospital” meaningful use. RECs can use the funds exclusively to work with EPs in hospital-owned or affiliated clinics. So rural hospitals represented by RECs without dedicated hospital programs will likely not get access to hospital-focused technical assistance.
Here in Wisconsin we have both EP and rural hospital programs, and we’re in the process of performing meaningful use gap assessments for all qualifying providers that sign up. Additional services (MU dashboards, security assessments, quality program assistance, and others) are being developed based on provider input. Both WORH and RWHC are playing leadership roles in the development of the rural hospital program.
Associated previous posts:
Wisconsin Information Exchange Efforts:
After a year of intense collaborative planning, on December 22nd Wisconsin’s Statewide HIE Plan was approved by ONC, and $9.4 million was released for the implementation of our State’s HIE network. The Wisconsin Statewide Health Information Network (WISHIN) will serve as the network’s governing organization and the Wisconsin Health Information Exchange (WHIE) will act as the network’s technical manager and provide early stage technical assistance to EPs and hospitals that want to participate in information exchange. The planning process involved strong collaboration between Wisconsin’s Department of Health Services and the provider community, and we look forward to the promise of (early-stage) statewide HIE in 2011.
RAND Study Reaffirms Fundamental Question:
Even as many of us engage in all-things-HIT, questions remain regarding the underlying assumption that EHRs are the pixie dust that will cure whatever ails our healthcare delivery system. According to a December 23rd RAND study, “hospitals with basic electronic health records demonstrated a significantly higher increase in quality of care for patients being treated for heart failure. However, similar gains were not noted among hospitals that upgraded to advanced electronic health records. And hospitals with electronic health records did not have higher quality care among patients treated for heart attack or pneumonia.”
The study goes on to say: “Most of the current knowledge about the relationship between health information technology and quality comes from a few hospitals that may not be representative, such as large teaching hospitals or hospitals that were among the first to adopt electronic health records.”
This supports a 2006 AHRQ study that (in-a-nutshell) found that “using existing published evidence, it is not possible to draw firm conclusions about which HIT functionalities are most likely to achieve certain health benefits.”
The lesson here is that we need to keep our hype and propaganda instincts in check. And moving forward we need to be willing to make adjustments based on what we learn. I hope everyone excuses me for pointing out the obvious: HIT interventions that may provide benefits in large hospitals may not (for a host of reasons) have the same effect on smaller organizations.
Implications for the Digital Divide:
Next December, when we look back over 2011, I think we will find that the vast majority of meaningful users will be those providers that already started with advanced EHR systems and just needed to do some tweaking to qualify. The structure of the incentive program is such that the lion’s share of the funds will (by design) go to those that already have EHR systems rather than to those who need them but have not been able to afford them. So yes, the digital divide is likely to increase over the next several years.
But even if advanced EHR users are the primary recipients, disadvantaged providers that engage the incentive program will still have opportunities. Those that qualify for the Medicaid program will receive funds for “adopting or upgrading” (rather than achieving meaningful use) in Year 1, and those with reasonably robust HIT programs in place have a good chance of qualifying for Stage 1 MU at least at some point during the duration (2011-2015) of the Medicare program.
The big wildcard now is Stage 2. Will the Agencies plow ahead in a way that makes what is currently a great challenge (Stage 1) effectively out of reach for many smaller organizations (when faced with Stage 2)? Or will they see the wisdom of promoting safe and effective (i.e. reasonably timed) EHR adoption, using actual HIT adoption data to make course corrections as needed? Next year should tell.