Third Annual Status of Electronic Health Records in Missouri Hospitals HIDI SPECIAL REPORT

Transcription

1 Third Annual Status of Electronic Health Records in Missouri Hospitals HIDI SPECIAL REPORT OCTOBER 2013

2 HIDI SPECIAL REPORT Introduction Throughout the past three years, the nation s hospitals have made steady progress in their adoption of electronic health records. This is largely because of the Health Information Technology for Economic and Clinical Health Act that was included in the 2009 economic stimulus bill, which included funding to stimulate the adoption of electronic health records and supporting technology in the United States. The HITECH act stipulates financial incentives for health care providers that demonstrate the meaningful use of EHR. Incentives, which began in 2011, will be offered through 2015 as different stages of adoption are met. After 2015, penalties may be levied for organizations or individual providers that fail to successfully implement and use this technology. Although not all are eligible, more than 3,800 hospitals nationwide approximately 80 percent have received EHR incentive payments for their progress in achieving meaningful use according to an April 2013 report from the Office of the National Coordinator for Health Information Technology i. The Centers for Medicare & Medicaid Services continues to report progress. More than 13 million reminders about appointments, tests or check-ups have been sent to patients using EHR technology. More than 190 million e-prescriptions have been sent using EHRs. With EHRs, 4.6 million patients have received an electronic copy of their health information. Through the use of EHRs, 4.3 million patient care summaries were shared between providers across patient care settings. Health care providers have checked drug and medication interactions more than 40 million times using EHRs. EHRs are transforming patientprovider relationships through improved care coordination, reduced duplicative tests and procedures, and better managed patient care, resulting in better overall health outcomes. Missouri s health care providers also are demonstrating unprecedented levels of EHR adoption and utilization. The steady progress they have made since 2012 promises new opportunities for quality improvement in Missouri s health care delivery system. These significant investments by hospitals boost economic growth through expansion of jobs in the state s health care and information technology sectors. The Missouri Hospital Association first reported on the adoption of EHR systems by the state s hospitals in June As of June 2013, 80 of Missouri s acute care hospitals have received nearly $170 million in Medicare EHR incentive payments as well as an additional $86 million in Medicaid incentive payments. Beginning in 2015, failure to adopt the health information technology necessary to implement EHRs will result in penalties that increase and never expire. The expected impact could be as much as 3 percent of all Medicare payments for inpatient care ii. In 2009, MHA conducted its first survey of hospitals information technology efforts to inform the hospital community and policymakers regarding the progress of EHR adoption. This report summarizes the 2012 survey responses for various groupings of the 151 Missouri hospitals that completed the survey. Page 1

3 Status of Electronic Health Records in Missouri Hospitals - October 2013 EHR ADOPTION Of the hospitals surveyed, 72 percent reported owning an EHR system that has been certified by the Office of the National Coordinator for Health Information Technology. Missouri hospitals are using a variety of systems from EHR inpatient and outpatient system vendors, including three hospitals that are using self-developed systems as shown in Charts 1 and 2. The same vendor was being used by 69 percent of hospitals in 2012 for inpatients and outpatients. The Missouri market share across vendors has been mostly flat since READINESS TO MEET MEANINGFUL USE REQUIREMENTS Stage 1 Stage 1 meaningful use is the first phase of the incentive program. Its criteria focus on electronically capturing health information in a coded format, using that information to track key clinical conditions, communicating that information for care coordination purposes and initiating the reporting of clinical quality measures and public health information. According to CMS, 80 of Missouri s 111 acute care hospitals (72 percent) have achieved Medicare Stage 1 meaningful use, and an additional 21.6 percent report they plan to attest that achievement during Among the multiple reasons hospitals report uncertainty about their ability to meet meaningful use, the most frequent challenges CHART 1: Top 5 Inpatient EHR Systems in Missouri Hospitals, % 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% MEDITECH McKesson Epic CPSI Cerner CHART 2: Top 5 Outpatient EHR Systems in Missouri Hospitals, % 14% 12% 10% 8% 6% 4% 2% 0% CHART 3: Missouri Acute Care Hospitals EHR Adoption Progress, Clinical Decision Support Clinical Quality Measure Reporting Maintain Updated Problem List CPOE Medication Orders Maintain Active Allergy Lists Drug Interaction Checks Maintain Active Meds List Record Demographics Record Smoking Status Vital Sign Charting Electronic Copy of Health Info Electronic Discharge Instructions Exchange Key Clinical Info % 50% 100% MEDITECH Epic CPSI Allscripts/Eclipsys Cerner Page 2

4 HIDI SPECIAL REPORT are maintenance costs, up-front costs and aggressive timeframes. A hospital s decision to first attest to meaningful use depends on multiple factors, including the ability to absorb the total cost of ownership of the project and to engage key stakeholders and physicians, tempered by the organization s overall ability to meet the aggressive requirements. Acquisition costs alone can be in the millions of dollars, and there are ongoing significant maintenance costs. The adoption of an EHR is an ongoing commitment requiring the integration of resources throughout the hospital that involves all of the patient care staff. Missouri acute care hospitals with higher numbers of beds attest to Stage 1 meaningful use at higher rates, as illustrated in Chart 4. They tend to excel in specific core objective areas such as exchanging key clinical information, maintaining active medication lists, performing drug interaction checks, maintaining active allergy lists, vital sign charting, electronic discharge instructions, and recording smoking status and demographics. Core objectives that appear to be more problematic for hospitals to implement are clinical decision support, computerized physician order entry, medication orders, maintaining updated problem lists and reporting clinical quality measures. CHART 4: Missouri Acute Care Hospitals Stage 1 Meaningful Use Achievement by Bedsize, 2012 All Bed Size Categories % 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% CHART 5: Missouri Acute Care Hospitals Reporting Progress in Active Exchange of Data With Providers Outside of System, Patient Demographics Laboratory Results Medication History Radiology Reports Clinical/Summary Care Record (Any Format) Other Types of Patient Data* Attested *New data element collected on the 2012 IT Supplement Survey. The exchange of key clinical data elements is essential to achieving improved care coordination across providers, a key requirement in Stage 2. The health information exchange landscape in Missouri continues to evolve. In 2012, 86 of 111 hospitals report they are actively exchanging some form of data with providers outside of their own Not Attested 0% 10% 20% 30% 40% 50% 60% hospital system. Almost 13 percent of Missouri s acute care hospitals reported the active exchange of data within a health information exchange or regional health information organization. Chart 5 shows the progression from 2010 to 2012 in the level of health information exchange by Missouri hospitals with other hospitals or ambulatory Page 3

5 Status of Electronic Health Records in Missouri Hospitals - October 2013 CHART 6: Stage 1 Meaningful Use Menu Set Achievement Capacity Missouri Acute Care Hospitals 2012 Drug Formulary Checks Advanced Directives Clinical Lab Results 61 percent and 76 percent of hospitals respectively indicating they have either met or have the capacity to meet the objective. To date, 97 have higher thresholds. For example, the computerized physician order entry measure for Stage 2 requires 60 percent of medication orders to be recorded using CPOE, compared to 30 percent in Stage 1. Lists of Patients by Conditions Patient-Specific Education Medication Reconciliation Summary of Care Record Submit Electronic Immunizations Submit Reportable Lab Results Submit Syndromic Surveillance service providers outside their own system. The most significant areas of improvement this year versus last year were in the active exchange of laboratory and clinical/summary care record data, with percentage point increases of 11.8 and 9.9, respectively. 0% 50% 100% Stage 1 menu objective / Stage 2 required core objective Hospitals also must satisfactorily meet five out of 10 menu objectives as part of Stage 1 meaningful use. For most of the 10 objectives, the overwhelming majority of Missouri s hospitals have the capacity to meet the given criteria as displayed in Chart 6. The objectives that are proving to be more challenging are clinical lab results and summary of care record, with Stage 2 In August 2012, CMS announced the requirements of meeting Stage 2 meaningful use, which places an emphasis on using technology to improve care coordination and better engage patients. As a prerequisite to attaining meaningful use in Stage 2, hospitals must achieve meaningful use in Stage 1. Among the Stage 2 requirements are 16 core objectives and six menu objectives. Hospitals must successfully report on all 16 core objectives and three of the six menu objectives. Many of the objectives apply a higher threshold to the hospitals relative to Stage 1 objectives. This survey did not indicate this Stage 1-Stage 2 threshold distinction across its questions. Stage 2 achievement capacity measures identified in this report are proxies based on the capacity to meet the objective in general, not necessarily the capacity of meeting the objective qualified by matching or surpassing the associated Stage 2 thresholds. Page 4

6 HIDI SPECIAL REPORT The Stage 2 objective readiness for Missouri s acute care hospitals by bed size and number of hospitalspecific objectives reported are displayed in Table 1 and Chart 7. Generally, hospitals with smaller numbers of beds reported readiness to meet less than half of the required Stage 2 meaningful use core objectives. Hospitals within the largest two bed size categories indicate the highest rates of capacity readiness to meet all 16 of the Stage 2 meaningful use core objectives. But overall, the survey indicates Missouri acute care hospitals readiness to achieve all objectives required for Stage 2 is very low (3.6 percent). The good news is that Missouri s acute care hospitals are steadily making progress toward meeting the meaningful use expectations for Stage 2, as seen in Charts 8 and 9. The specific objectives that demonstrate this progression toward Stage 2 meaningful use are the use of clinically-relevant information from certified EHR technology to identify patient-specific education resources and provide to patients, medication reconciliation and electronic medication administration records. Chart 7: Missouri Acute Care Hospitals Stage 2 Meaningful Use Core Objective Readiness Capacity by Bed Size Percentage of Hospitals 100% 75% 50% 25% 0% Bed Size Categories Table 1: Distribution Percentage of Missouri Acute Care Hospitals Stage 2 Meaningul Use Core Objective Achievement Capacity by Bed Size Bed Size Minimal Capacity Exists to Meet Stage 2 Objectives Category All % 4.3% 30.4% 52.2% 2.2% % 0.0% 20.0% 66.7% 6.7% % 15.4% 30.8% 46.2% 0.0% % 0.0% 16.7% 83.3% 8.3% % 0.0% 33.3% 66.7% 8.3% All Bed Sizes 9.0% 5.4% 27.9% 57.7% 3.6% Page 5

7 Status of Electronic Health Records in Missouri Hospitals - October 2013 Chart 8: Missouri Acute Care Hospitals Stage 2 Meaningful Use Core Objective Readiness Capacity Lists of Patients by Conditions Medication Reconciliation Vital Signs Record Smoking Status Patient-Specific Education emar CPOE Summary of Care Record Demographics Submit Electronic Immunizations Submit Syndromic Surveillance Submit Reportable Lab Results Clinical Lab Results Clinical Decision Support Provide Patients Ability to View, Download and Transmit info About Admit 0% 20% 40% 60% 80% 100% Chart 9: Missouri Acute Care Hospitals Stage 2 Meaningful Use Core Objective Readiness Capacity Detail, by Bed Size CPOE Demographics Vital Signs Record Smoking Status Clinical Decision Support Provide Patients Ability to View, Download and Transmit Info About Admit Clinical Lab Results Lists of Patients by Conditions Patient-Specific Education Medication Reconciliation Summary of Care Record The capacity for Stage 2 objectives that are least likely to be already in place are the use of clinical decision support, the incorporation of clinical lab results into certified EHR technology and providing patients with the ability to view, download and transmit information about admissions. Hospitals progress toward the specific objective of providing patients with the ability to view, download and transmit admission and ED information is estimated using a proxy based on three of the measures in Chart 10 on the following page. (Patients viewing information from their health/medical records online, patients downloading information from their health/ medical records and patients having the ability to request an amendment to change/update their health/medical records.) As a whole, Missouri acute care hospitals just eclipsed the 50 percent mark on their combined capability to provide patients with the ability to view information from their health/medical records online and the ability to request an amendment to change/update their health/medical records. More than 50 percent of the hospitals with 400 or more beds reported the capacity to meet all three objectives. Submit Electronic Immunizations Submit Reportable Lab Results Submit Syndromic Surveillance emar 0% 50% 100% Page 6

8 HIDI SPECIAL REPORT CHART 10: Percentage of Missouri Acute Care Hospitals EHR Patient Engagement Readiness Functionality by Bed Size Bed Size Category All Bed Categories % 50% 100% View information from their health/medical record online Download information from their health/medical record Request an amendment to change/update their health/medical record Request refills for prescriptions online Schedule appointments online Pay bills online Submit patient-generated data (e.g., blood glucose, weight) None of the above Do not Know Clinical Quality Measures Beginning in federal fiscal year 2014, the reporting of clinical quality measures will change for all hospitals, regardless of whether they participate in Stage 1 or Stage 2 meaningful use. Hospitals will be required to report on the final 2014 Clinical Quality Measures and those participating in Stage 1 in 2014 may report CQM data through attestation. But, CQM results must be captured using 2014 edition criteria. Hospitals participating in Stage 2 in 2014 will be required to submit CQMs electronically using 2014 edition criteria. CQM reporting is no longer a core objective because it is required that all hospitals report to demonstrate meaningful use. They must submit 16 of 29 approved CQMs from at least three of the six key health care policy domains recommended by the U.S. Department of Health and Human Services National Quality Strategy using EHR technology that has been certified to the 2014 edition standards. Health care policy domains include patient and family engagement, patient safety, care coordination, population and public health, efficient use of health care resources and clinical processes/effectiveness. CQMs are comprised of definitions, measure logic, data elements and value sets. Four federal agencies the Agency for Healthcare Research and Quality, CMS, the National Library of Medicine and the ONC are providing these components in various formats to be understood by technical, nontechnical and clinical consumers. Page 7

9 Status of Electronic Health Records in Missouri Hospitals - October 2013 Summary The CMS-mandated migration to the industry-wide installation of hospital-based, technologicallyadvanced EHR systems brings the promise of improved care coordination, quality, safety and efficiency while maximizing the patient s engagement in their medical care. But, it includes aggressive deadlines, numerous obligations with escalating requirement thresholds, challenging and costly implementation, expensive and permanent maintenance obligations and noncompliance penalties that increase, never expire and could total as much as 3 percent of inpatient Medicare payments. Striking increases in the adoption rates of comprehensive EHR systems nationwide have been most significant from 2011 to Defined as having EHR adoption across all 24 functions in all units, comprehensive EHR systems have increased in U.S. hospitals six-fold since 2009 and have nearly doubled from 2011 to Nationally, 16.9 percent of non-federal acute care hospitals have adopted comprehensive EHR systems. Comparatively, Missouri has more than kept pace by adopting comprehensive EHR systems across 23.4 percent of its non-federal acute care hospitals as of iii Other research has highlighted the challenges associated with developing a business model that sufficiently addresses the long-term financial sustainability of EHR installation. iv EHR adoption incentives already have been reduced by federally mandated sequestration and will eventually be replaced by penalties for noncompliance, which illustrates the importance of the development of a long-term financial commitment by policy makers. HIT advocacy organizations including the American Hospital Association and College of Healthcare Information Management Executives have expressed concern about the approaching deadlines for Stage 2 meaningful use, and recommend greater flexibility for providers in meeting Stage 2 to ameliorate the all or nothing problem (failure to meet part of an objective, or narrowly missing a threshold results in overall failure to meet meaningful use), recognize that the level of change in Stage 2 will take time to accomplish. Based on the conditions believed to promote program success, CHIME strongly recommend[ed] a one-year extension to [achieve] Stage 2 before progressing to Stage 3 of meaningful use in a letter addressed to six U.S. senators v who previously expressed their concerns in a white paper vi regarding the efficacy and sustainability of IT adoption as the implementation program is currently designed. CHIME continued stating, A year extension of Stage 2 will give providers the opportunity to optimize their EHR technology and achieve the benefits of Stage 1 and Stage 2; it will give vendors the time needed to prepare, develop and deliver needed technology to correspond with Stage 3; and it will give policymakers time to assess and evaluate programmatic trends needed to craft thoughtful Stage 3 rules. Missouri hospitals continue to make formidable strides toward the widespread adoption of meaningful use of EHR technology. Their HIT investments will improve the quality and efficiency of care provided to patients treated in Missouri hospitals and will continue to contribute to the economic vitality of the state. Policy makers should be mindful to develop requirements that strike an appropriate balance between allowing for adequate planning and preparation to best meet the HIT implementation standards and developing aggressive resultsdriven expectations that may have the unintended consequence of undermining the quality of the HIT product. Over the past several years, Missouri s hospitals both urban and rural have made good use of federal HIT funding to bring about rapid deployment of new and improved information systems across the state. Future policies must continue to effectively reinforce compliant EHR adopting hospitals with incentives to reinvest in HIT while paving the way to providing the best possible care to Missouri patients. Page 8

10 HIDI SPECIAL REPORT Appendix Missouri Regions Number of Hospitals Attesting to Stage 1 Number of Acute Care Hospitals Central Missouri 9 15 Kansas City Metropolitan Area Northeast Missouri 6 9 Northwest Missouri 6 8 Southeast Missouri 7 16 Southwest Missouri St. Louis Metropolitan Area Total Bed Size Category Number of Hospitals Attesting to Stage 1 Number of Acute Care Hospitals Total Note: This report is based on IT Supplement Survey data reported as of April 2013 and CMS attestation information as of June Subsequent EHR adoption progress achieved is excluded from this report. Page 9

11 Status of Electronic Health Records in Missouri Hospitals - October 2013 References i The Office of the National Coordinator for Health Information Technology (ONC). (June, 2013). Update on the adoption of health information technology and related efforts to facilitate the electronic use and exchange of health information. Washington, DC. Retrieved from: healthit_and_relatedefforts.pdf ii DesRoches, C., Charles, D., Furukawa, M., Joshi, M., Kralovec, P., Mostashari, F., Worzala, C., & Jha, A. (2013). Adoption of electronic health records grows rapidly, but fewer than half of US hospitals had at least a basic system in Health Affairs, 32(8) iii Charles, D., King, J. Patel, V., Furukawa, M (March 2013). Adoption of Electronic Health Record Systems Among U.S. Non-Federal Acute Care Hospitals: Retrieved from default/ files/oncdatabrief9final.pdf iv Adler-Milstein, J., Bates, D., Jha, A. (2013). Operational health information exchanges show substantial growth, but long-term funding remains a concern. Health Affairs, 32 (8) v Branzell, R. & Hickman, G. (2013, May 6). Letter to The Honorable John Thune, The Honorable Lamar Alexander, The Honorable Pat Roberts, The Honorable Richard Burr, The Honorable Tom Coburn and The Honorable Mike Enzi. Retrieved August 28, 2013, from CHIME_Response_to_Reboot_Re-examining_the_Strategies_Needed_to_Successfully_Adopt_Health_ IT.pdf. vi Thune, J., Alexander, A., Coburn, T., Roberts, P., Burr, R., Enzi, M. (2013, April 16). Reboot: Re-examining the Strategies Needed To Successfully Adopt Health IT. Retrieved August 28, 2013, from gov/public/index.cfm/files/serve?file_id=0cf0490e-76af-4934-b534-83f5613c7370 Page 10

12 2013 Hospital Industry Data Institute P.O. Box 60 Jefferson City, MO /13