Status of Electronic Health Records in Missouri Hospitals HIDI SPECIAL REPORT JULY 2012

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1 Status of Electronic Health Records in Missouri Hospitals HIDI SPECIAL REPORT JULY 2012

2 HIDI SPECIAL REPORT INTRODUCTION The steady progress that Missouri hospitals continue to demonstrate in their adoption of electronic health records promises new opportunities for quality improvement in Missouri s health care delivery system. Hospitals significant investments in health information technology and EHR systems 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 Missouri hospitals in June Since then, 36 hospitals in Missouri have received more than $67 million in Medicare EHR incentive payments, and Missouri hospitals have received another $46 million in Medicaid incentive payments. These incentive payments, created through the American Reinvestment and Recovery Act that includes the Health Information Technology for Economic and Clinical Health Act, mandate that providers meet required criteria for meaningful use of EHRs. Failure to adopt HIT results in penalties for providers. shown in Charts 1 and 2. Of the 125 hospitals reporting the use of vendors for EHR, 84 use the same vendor for inpatients and outpatients. CHART 1: Inpatient EHR Vendor and Number of Hospitals Others 6.6% VHA - CPRS 2.0% Allscripts/ Eclipsys 2.0% NONE 17.1% Selfdeveloped 2.6% Meditech 18.4% HMS 5.9% McKesson 15.1% Epic 10.5% CPSI 11.2% Cerner 8.6% CHART 2: Outpatient EHR Vendor and Number of Hospitals Since 2009, MHA has surveyed hospitals through the Information Technology Supplement to the Annual Licensing Survey of Missouri Hospitals. Data from the 2011 IT Supplement Survey are intended to inform policymakers, hospital CEOs and others about the progress of EHR adoption in Missouri and hospitals readiness to meet meaningful use requirements. Missouri s annual survey, viewed as the definitive source for aggregate hospital data and trend analysis, is a joint project of MHA, the American Hospital Association and the Missouri Department of Health and Senior Services. The 2011 IT Supplement Survey was mailed to 154 Missouri hospitals in March 2012 and respondents submitted information on their current HIT adoption. This report summarizes survey responses for 152 Missouri hospitals that completed the survey. EHR ADOPTION Of the hospitals surveyed, 65 percent reported they own an EHR system that has been certified by the Office of the National Coordinator for Health Information Technology. Missouri hospitals own various systems from several EHR vendors, including five hospitals that are using self-developed systems. The EHR inpatient and outpatient system vendors are Page 1 eclinical Works 2.6% Others 17.1% NextGen 4.6% GE 4.6% NONE 19.1% McKesson 5.3% Meditech 13.8% Epic 9.2% CPSI 8.6% Cerner 7.2% Allscripts/ Eclipsys 7.9% The 2011 IT Supplement Survey organizes 24 key EHR functions into several categories electronic clinical documentation, results viewing, computerized provider order entry (CPOE) and decision support. Comparisons with prior years are based on these 24 key items. Hospitals report their level of EHR adoption on a scale that ranges from not in place and not considering implementing to fully implemented across all units. Missouri s hospitals have made steady progress toward the adoption of EHRs. In 2009, the average number of key functions implemented was 8.9, compared to 10.7 in In 2011, the average number of the 24 key EHR functions implemented for 152 reporting

3 Status of Electronic Health Records in Missouri Hospitals hospitals was Among 111 acute care hospitals, the average was Chart 3 shows the advancement in EHR adoption that has occurred between 2010 and The level of adoption by EHR key functionality is shown in Chart 4. Hospitals have significantly invested resources in an effort to progress toward EHR adoption in all key areas. More than 90 percent of None hospitals report the implementation of electronic clinical documentation for patient demographics. 0% 10% 20% 30% 40% Hospitals also have made significant progress toward electronically viewing diagnostic test results and images. The greatest progress occurred in the areas of CPOE. CHART 4: EHR Key Function Adoption Level Studies show that CPOE reduces costs and improves patient care by reducing Clinical Documentation - Patient Demographics 89.5% 3.3% length of stay and repeat lab tests, as Clinical Documentation - Physician Notes 30.9% 15.8% well as improved turnaround time for Clinical Documentation - Nursing Assessments 61.8% 9.9% laboratory, pharmacy and radiology requests. Chart 4 shows if the requirements were met for all units or for one or more units. Clinical Documentation - Problem Lists Clinical Documentation - Medication Lists 52.6% 65.8% 11.8% 9.9% Chart 5 shows progress made toward adoption by key function in 2011 compared to the previous year. The 2011 IT Supplement Survey indicates steady but slow improvement. EHR adoption by hospital staffed bed size is shown in Chart 6. An observable gap in adoption of key EHR functions between large and small hospitals in Missouri still exists. Larger hospitals are much more likely to have higher levels of adoption more than half of reporting hospitals with 250 or more staffed beds have implemented 19 or more key functions. Conversely, more than a third of small hospitals with fewer than 100 staffed beds have less than seven functions implemented. However, some small Missouri hospitals report all 24 functions implemented. Of the hospitals surveyed, 4.6 percent report that they have not implemented any of the 24 basic EHR functions Page 2 CHART 3: Percent of Hospitals in 2010 Versus 2011 by EHR Key Function Adoption Level Clinical Documentation - Discharge Instructions Clinical Documentation - Advanced Directives Results Viewing - Laboratory Reports Results Viewing - Radiology Reports Results Viewing - Radiology Images Results Viewing - Diagnostic Test Results Results Viewing - Diagnostic Test Images Results Viewing - Consultant Reports CPOE - Laboratory Tests CPOE - Radiology Tests CPOE - Medications CPOE - Consultation Requests CPOE - Nursing Orders Decision Support - Clinical Guidelines Decision Support - Clinical Reminders Decision Support - Drug Allergy Alerts Decision Support - Drug-Drug Interactions Decision Support - Drug-Lab Interactions Decision Support - Drug Dosing Support All Units 61.8% 59.9% 59.9% 53.3% 40.8% 38.2% 36.2% 32.9% 41.4% 38.8% 38.8% 61.2% 49.3% 45.4% 82.2% 81.6% 81.6% 67.8% 67.8% 11.2% 8.6% 9.2% 10.5% 7.9% 21.7% 22.4% 20.4% 19.7% 11.8% 18.4% 17.1% 5.9% 3.9% 4.6% 13.8% 11.8% 11.8% 13.2% 0% 50% 100% One or More Units continued

4 HIDI SPECIAL REPORT Chart 7 displays a steady achievement increase in key function adoption during a three-year period. READINESS TO MEET MEANINGFUL USE REQUIREMENTS The 2011 IT Supplement Survey made data available on 14 functions that either match or are a close proxy for the 14 criteria established by the Office of the National Coordinator as core criteria required to meet stage one meaningful use. The 14 functions included in the 2011 IT Supplement Survey are shown in Chart 8. The core objective achievement proxy is lenient implementation in one or more units was counted as having meaningful use capacity for that hospital. This stage one meaningful use core readiness measure was used as a proxy in understanding Missouri hospitals readiness to have achieved or be positioned to achieve stage one meaningful use. Not all hospitals are eligible for Medicare EHR incentives. The narrative in the following section summarizes the readiness status of Missouri s 111 acute care hospitals. More than 83 percent of hospitals reported they plan to attest as a meaningful user of EHRs either before or during federal fiscal year 2013, as shown in Table 1. Twenty-eight hospitals reported reasons for uncertainty regarding their ability to meet meaningful use, with some hospitals reporting several reasons. Among the top reasons reported by hospitals for not pursuing Medicare or Medicaid meaningful use incentive payments are acquisition costs and maintenance. Hospital leaders are carefully evaluating the timing of attempting to meet meaningful use. The decision on when a hospital will first attest to meaningful use depends CHART 5: Percent EHR Key Function Adoption Level 2010 and Added Percent Adoption in 2011 Reporting Hospitals in Each Year Patient Demographics Physician Notes Nursing Assessments Problem Lists Medication Lists Discharge Instructions Advanced Directives Laboratory Reports Radiology Reports Radiology Images Diagnostic Test Results Diagnostic Test Images Consultant Reports Laboratory Tests Radiology Tests Medications Consultation Requests Nursing Orders Clinical Guidelines Clinical Reminders Drug Allergy Alerts Drug-Drug Interactions Drug-Lab Interactions Drug Dosing Support 37.9% 63.4% 57.9% 72.4% 64.8% 56.6% 62.8% 57.2% 60.7% 52.4% 49.7% 46.2% 42.8% 47.6% 42.1% 42.8% 53.8% 50.3% 86.9% 83.4% 79.3% 83.4% 75.9% 73.1% 8.8% 6.5% 6.6% 10.1% 10.9% 10.4% 9.9% 8.6% 12.3% 13.2% 7.4% 8.2% 8.3% 3.2% 8.2% 11.9% 6.3% 8.4% 5.7% 6.5% 4.7% 6.2% 2.7% 5.9% 0% 20% 40% 60% 80% 100% 2010 Percent 2011 Percent Added CHART 6: EHR Key Function Adoption Level by Hospital Bed Size 400 or More Beds Beds Beds Beds 1-49 Beds All Hospitals 0% 10% 20% 30% 40% 50% 60% 70% None Page 3

5 Status of Electronic Health Records in Missouri Hospitals on multiple factors, including the ability to absorb the total cost of ownership of the project; the ability to engage key stakeholders, including physicians; and the organization s overall ability to meet the aggressive requirements of meaningful use. Acquisition costs alone can be in the millions of dollars. Costs for annual recurring maintenance and for upgrades to maintain required ONC certification are significant. Total cost of ownership of an EHR includes initial investment costs and other costs associated with the adoption and ongoing use of the technology, including maintenance, staff training, related hardware infrastructure and employees time to implement and support the system. The adoption of an EHR is an ongoing commitment requiring the integration of resources across the hospital organization that involves everyone associated with delivering patient care. Using the core objective achievement proxy in the 2011 IT Supplement Survey, 27 hospitals reported having functionality in place to meet all 14 of the required core functions for stage one meaningful use. Using this proxy, Charts 8 and 9 show the distribution of the meaningful use core objective achievement capacity by bed size category. Using the meaningful use core objective achievement capacity proxy, hospitals excel in safeguarding protected health information and exchanging key clinical information. They also have made their CHART 7: Missouri Acute Care Hospitals EHR Average of 24 Criteria by Year Survey Year % 50% 100% Percent Distribution best progress toward meeting the core objectives for recording patient demographics and other key clinical information, including allergy lists, smoking status and vital sign charting. However, Missouri hospitals are struggling most with implementing CPOE and the requirement to implement at least one clinical decision support rule related to a high priority hospital condition. Even more challenging is the core objective that requires the generation and reporting of clinical quality measures. Both of these complex functions require a high level of physician engagement and integration within the hospital. Hospitals are required to generate 15 clinical quality measures directly from a certified EHR to meet the single core objective for reporting quality measures. Hospitals also report difficulty with generating an electronic copy of health results through currently certified EHR systems TABLE 1: Hospital Plans to Attest as a Meaningful User and Date Number Percent 24 Average Meaningful Use Core Objective Achievement Level No Response / Do Not Know % 14.8 Not Planning to Attest 1 0.9% 0.0 Yes, in FFY 2011 (by Sept. 30, 2011) % 18.0 Yes, in FFY 2012 (by Sept. 30, 2012) % 17.0 Yes, in FFY 2013 (by Sept. 30, 2013) % 11.1 Yes, in FFY 2015 (by Sept. 30, 2015) 4 3.6% 9.5 Not Eligible for Either Medicare or Medicaid EHR Incentives 2 1.8% 5.5 Total % 14.8 Page 4 continued

6 HIDI SPECIAL REPORT The exchange of key clinical data elements is essential to achieving improved care coordination across providers. The health information exchange landscape in Missouri continues to evolve. From the 2011 IT Supplement Survey, almost 13 percent of hospitals reported the active exchange of data within a health information exchange or regional health information organization. Out of 111 hospitals, 67 report they are actively exchanging some form of data with providers outside of their own hospital system. The remaining 44 hospitals did not report exchanging data with other hospitals or ambulatory service providers outside of their systems. Chart 10 displays the level of health information exchange by Missouri hospitals with hospitals or ambulatory providers outside their own system. In addition to the core objective requirements, hospitals also must meet five objectives from a menu set of measures, including one objective to submit electronic syndromic surveillance data to public health agencies to be considered meaningful users of HIT. The 2011 IT Supplement Survey captured hospital readiness to achieve each of the 10 optional measures; these results are shown in Chart 11. In March 2012, the Centers for Medicare & Medicaid Services released a proposed rule for the requirements to meet stage two meaningful use. Stage one menu objectives that are proposed to be required core objectives in stage two are highlighted in yellow in Chart 11. Required core objectives in stage two have higher thresholds. For example, the proposed CPOE measure for stage two requires 60 percent of orders to be recorded using CPOE, compared to the 30 percent requirement in stage one. Final requirements for stage two are expected later in CHART 8: Missouri Acute Care Hospitals Meaningful Use Core Objective Achievement Capacity Detail by Bed Size CPOE Medication Orders Drug Interaction Checks Maintain Updated Problem List Maintain Active Meds List Maintain Active Allergy Lists Record Demographics Vital Sign Charting Record Smoking Status Clinical Quality Measure Reporting Clinical Decision Support Electronic Copy of Health Info. Electronic Discharge Instructions Exchange Key Clinical Info. Protect Electronic Health Info. 0% 50% 100% Percent of Hospitals All Hospitals CHART 9: Missouri Acute Care Hospitals Average Meaningful Use Core Objective Achievement Capacity Bed Size Category IT Supplement Core Objective Achievement Capacity IT Supplement Core Objective Achievement Capacity Page 5

7 Status of Electronic Health Records in Missouri Hospitals CHART 10: Hospitals Reporting Active Exchange of Data With Providers Outside of System Radiology Reports Medication History Laboratory Results Clinical/Summary Care Record (Any Format) Clinical/Summary Care Record (CCR or CCD Format) Patient Demographics 0% 10% 20% 30% 40% 50% 60% SUMMARY The national vision to improve care coordination, quality, safety and efficiency while maximizing patient engagement in their medical care, largely depends on the widespread adoption of meaningful use of HIT. In Missouri, steady progress toward this goal continues. However, MHA recognizes that the adoption of an EHR system and its related challenges and opportunities are considerable. Missouri hospitals HIT investments will improve the quality and efficiency of care provided to patients treated in Missouri hospitals and contribute to the economic vitality of the state. Policymakers must ensure future requirements allow for adequate planning and preparation to meet new standards. New policies, including requirements to achieve incentives, must ensure that no provider or patient is left behind. CHART 11: Meaningful Use Menu Set Achievement Capacity by Bed Size Missouri Acute Care Hospitals 2011 IT Supplement Core Objective Achievement Capacity Drug Formulary Checks Advanced Directives Clinical Lab Results Lists of Patients by Conditions Patient-Specific Education Medication Reconciliation Summary of Care Record Submit Electronic Immunizations Submit Reportable Lab Results All Hosps Submit Syndromic Surveillance FOR FURTHER INFORMATION Theresa Rogers Senior Vice President of Data and Information Services Phone: 573/ , ext % 50% 100% Percent of Hospitals Stage one menu objectives that are proposed to be required core objectives in stage two. Page 6 continued

8 HIDI SPECIAL REPORT Appendix A: 2011 IT Supplement Survey Participating Hospital Characteristics Service General Medical and Surgical Non-Critical Access Hospitals Critical Access Hospitals Psychiatric Long-Term Acute Care Rehabilitation Children s General *Other Specialty Children s Psychiatric 6.5 **** Cancer 10.0 **** Children s Rehabilitation 0.0 **** Children s Orthopaedic 21.0 **** Total *Other Specialty - Children s Psychiatric, Children s Rehabilitation, Children s Orthopaedic and a cancer hospital Control State County City Hospital District Other Not-For-Profit Corporation Church-affiliated Partnership *Other Ownership Total *Other Ownership - Two Veterans hospitals, church-operated and individual ownership Missouri Regions Central Kansas City Metropolitan Area Northeast Northwest Southeast Southwest St. Louis Metropolitan Area Total Bed Size Category Total Hospital Industry Data Institute P.O. Box 60 Jefferson City, MO Appendix B: 2011 IT Supplement Survey Participating Acute Care Hospital Characteristics Service General Medical and Surgical Non-Critical Access Hospitals Critical Access Hospitals Control County City Hospital District Church-affiliated Other Not-For-Profit Corporation *Other Ownership Total *Other Ownership - State, church-operated, individual, city-county and partnership. Missouri Regions Central Kansas City Metropolitan Area Northeast Northwest Southeast Southwest St. Louis Metropolitan Area Total Bed Size Category Average EHR Key Function Adoption Level **** Total Appendix C - Listing of 24 EHR Key Functions Hospital-Based Computerized System Allowing for: 1. Electronic Clinical Documentation of Patient Demographics 2. Electronic Clinical Documentation of Physician Notes 3. Electronic Clinical Documentation of Nursing Notes 4. Electronic Clinical Documentation of Problem Lists 5. Electronic Clinical Documentation of Medication Lists 6. Electronic Clinical Documentation of Discharge Summaries/Instructions 7. Electronic Clinical Documentation of Advanced Directives 8. Results Viewing of Laboratory Reports 9. Results Viewing of Radiology Reports 10. Results Viewing of Radiology Images 11. Results Viewing of Diagnostic Test Results 12. Results Viewing of Diagnostic Test Images 13. Results Viewing of Consultant Reports 14. Computerized Provider Order Entry of Laboratory Tests 15. Computerized Provider Order Entry of Radiology Tests 16. Computerized Provider Order Entry of Medications 17. Computerized Provider Order Entry of Consultation Requests 18. Computerized Provider Order Entry of Nursing Orders 19. Decision Support for Clinical Guidelines 20. Decision Support for Clinical Reminders 21. Decision Support for Allergy Alerts 22. Decision Support for Drug-Drug Interaction Alerts 23. Decision Support for Drug-Lab Interaction Alerts 24. Decision Support for Drug Dosing Support Page 7 07/12

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