Beyond Modular Electronic Health Records: Meeting Your Meaningful Use Attestation Goals

White Paper Beyond Modular Electronic Health Records: Meeting Your Meaningful Use Attestation Goals Masha Paschal, MA, CSM August 2013

Table of Contents Executive Summary....................... 1 The Challenge.......................... 2 IT Options for MU Attestation................. 3 Choosing a Solution....................... 7 Creating a Team That Works.................. 8 Looking Forward........................ 10 References............................ 11

Executive Summary It s no secret that healthcare falls behind other industries in adopting the latest information technology (IT). 1 But over the last several years, federal, state, and local governments as well as healthcare providers and payers have begun looking to IT as a way to control rising healthcare costs. Although the federal government has made several attempts to improve the rates of IT adoption in healthcare, 2 no sweeping measures were introduced until Congress passed the American Recovery and Reinvestment Act (ARRA) in 2009. The ARRA legislation included a subsection, the Health Information Technology for Economic and Clinical Health (HiTECH) Act, providing nearly $20 billion in federal funds to incentivize hospitals and doctors to purchase and implement an electronic health record (EHR). To determine whether a healthcare provider is qualified to receive the incentive, the government created the Meaningful Use (MU) concept so named because healthcare providers must make meaningful use of certified EHR systems. The law specifies three components of MU: Use of certified EHR in a meaningful manner (e.g., electronic prescriptions) Use of certified EHR technology for electronic health information exchange (HIE) to improve healthcare quality Use of certified EHR technology to submit clinical quality measures (CQM) and other such measures selected by the U.S. Secretary of Health and Human Services Beyond Modular Electronic Health Records 1

Making strategic decisions is the key to success in adopting new IT technologies in healthcare and meeting MU requirements. The Challenge Information technology may not be as advanced in healthcare as in other industries, but this doesn t mean that healthcare organizations (HCOs) aren t interested in using technology to improve their care delivery and outcomes. Nonetheless, healthcare providers do not have as much flexibility as other technology users and often have requirements that can be met only by niche IT vendors. One vendor might provide an excellent nursing documentation solution that meets the requirements of most inpatient units, for example, but the same product could be seriously lacking when it comes to nursing documentation in labor and delivery units or for anesthesia purposes. Truven Health Analytics professionals have found that hospitals do not want to compromise with a product that meets only some of their needs. To bridge the gap, many follow a best-of-breed approach, carefully selecting products that meet the specialized needs of specific departments and units. Larger HCOs go even further by creating in-house products tailored specifically to their users needs. In some cases, HCOs use in-house applications to supplement shelf application shortcomings. In others, they actually replace vendor applications altogether, giving hospitals more control over their IT solutions. As a result, one HCO may use multiple applications sometimes up to a hundred from different vendors, or have a mix of vendor or in-house solutions. With the increased use of mobile healthcare applications, 3 this number is expected to grow. The MU requirements set forth in ARRA spotlight a problem with this IT approach: It does not easily facilitate the transfer of critical patient information. For example, a patient discharged after surgery might have updated allergy or medication lists that cannot be electronically transferred to the primary care provider (PCP). When this happens, it is up to the patient to provide a hard copy of this information to the PCP and hope that the PCP s office has an established process to integrate these data with the patient s records. Considering how critical this information could be to the patient s wellbeing and safety, there are too many opportunities for errors in this approach. As you can see from the example above, the use of numerous healthcare applications that do not communicate with one another complicates the ideal of one comprehensive digital healthcare record spanning the continuum of care. If a patient is seen by more than one specialist even within the same HCO duplicate tests and procedures can result. This can create an environment in which patients have less understanding and control over the quality of healthcare they receive. It is an enormous challenge for an HCO to bring numerous IT solutions into harmonious existence that will improve, rather than complicate, the clinician s role. More and more HCOs are now tackling this issue, with MU reporting requirements and other government healthcare initiatives as some of the major drivers. In 2012, a record number of hospitals more than 200 earned Hospitals & Health Networks Most Wired status. The survey the digital magazine used to identify the hospitals revealed that IT and IT departments now play a greater strategic role in hospitals and health systems than they did just a few years ago. 4 Making strategic decisions is the key to success in adopting new IT technologies in healthcare and meeting MU requirements. This paper focuses on the considerations related to meeting the CQM reporting requirement of MU. We outline several of the most prevalent scenarios that an HCO could experience in their efforts to meet the MU CQM requirements and what should be considered in each. 2 Beyond Modular Electronic Health Records

We ve found that to successfully meet the CQM requirements of MU, HCOs must take the right strategic approach when choosing a software system for their needs and devising a comprehensive plan involving hospital IT and clinical quality assurance personnel in equal parts to implement the solution. IT Options for MU Attestation Healthcare organizations that do not take advantage of MU incentive payments will be at a distinct disadvantage. According to the latest figures available, the Centers for Medicare & Medicaid Services (CMS) paid out nearly $12.7 billion in MU incentive payments to eligible healthcare providers and hospitals through February 2013. 5 As depicted in Figure 1, there has been a significant increase since the beginning of the program. Figure 1: Hospitals Receiving Meaningful Use Payments 5000 4500 4000 3500 3000 2500 2000 U.S. Hospitals Registered for the MU Program Number of Unique Hospitals With Incentive Payments Received 1500 1000 500 0 As of 2011 As of April 2012 As of February 2013 Source: Centers for Medicare & Medicaid Services Medicare payment reduction begins in federal fiscal year 2015 for hospitals that do not demonstrate MU of certified EHR technology. Doing nothing is no longer an option. But to overcome the problems outlined in this paper and meet the MU requirements economically, HCOs must consider their options carefully. Option 1 All-in-One Solution This option involves finding a vendor that can provide a complete EHR solution to address all MU requirements, including CQM reporting, as well as meeting most of the HCO s needs. Pros Having one technical solution and one vendor to deal with could simplify the IT life of your HCO. It will definitely simplify infrastructure and hardware requirements and that, in turn, will allow you to reduce the number of IT resources needed, your maintenance cost, license fees, and IT costs on the whole. Cons It can be challenging to find a solution that can meet all the needs of an HCO, particularly if it specializes in several clinical areas. In this case, some functionality that may be heavily used by the HCO would be lost. Beyond Modular Electronic Health Records 3

The purchase and implementation of an integrated EHR system could cost millions of dollars even for a smaller HCO. Such an overhaul could be costly, requiring you to replace not only existing software, but also hardware. Reportedly the New York City Health and Hospitals Corp., the largest municipal healthcare organization in the country, awarded a $302.8 million electronic medical record system contract to Epic Systems Corp., 6 a provider of wellknown, complete EHR solutions. The purchase and implementation of an integrated EHR system could cost millions of dollars even for a smaller HCO. For example, in November 2012 WakeMed Health & Hospitals, an 870-bed healthcare system, announced plans to spend $100 million on such an implementation. 7 If you already have software and/or hardware licenses, you might not be able to recover this expense. Moreover, you will have to retrain your staff to use new applications and adjust to new workflows. Retraining staff is both costly and time-consuming. An EHR selected for your HCO might not prove to be the right choice or might not deliver all that it promises. Currently EHRs offer different levels of clinical decision support and may not contain any surveillance or analytical functionality that could be deemed necessary by your clinical staff. The vendor providing the complete EHR functionality may not have expertise in CQM reporting. Beginning with MU Stage 2, CQM reporting involves several steps, including electronic submission of patient-level data to CMS. 8 This could be a very labor-intensive and complicated process requiring previous experience dealing with such submissions. The EHR may include all the MUrelated functions, but the vendor may not have the resources or the desire to develop the expertise in CQM reporting. Placing all EHR eggs in one basket is risky. A hospital will be completely dependent on one vendor and subject to whatever direction this vendor will choose as far as improving and changing their product as well as future license negotiations. More importantly, if the main vendor does not meet MU Stage 2 or 3 requirements, the HCO will fail to attest in the future and another solution will be needed evoking another set of expenses and effort, not to mention potential penalties from the CMS for not meeting the next stage of MU requirements on time. Questions to Consider Do you have financial resources to support a complete overhaul of your IT system? Can you justify the loss of some functions available in your current applications? Are they nice-to-have or critical operations your physicians rely on every day? Do the savings mentioned in the above pros outweigh the loss of some functionality and potential risks? Are you looking only at the short term to meet the immediate needs of CQM reporting for MU or are you considering the long-term management of CQM, clinical practice guidelines, and outcome improvements? 4 Beyond Modular Electronic Health Records

Option 2 In-House Solution This option involves developing an internal system that bridges the gap between your current applications and provides MU CQM reporting functionality. Pros This approach will allow you to not only design a solution to meet MU requirements, but also to address the specific needs of your hospital. This solution could be flexible enough to follow your current workflows with minimal changes needed, thus simplifying the adoption process and cutting the time needed for full implementation. If done correctly, it will engage future potential users. The more users feel that they had a chance to provide input, the more interested they will be in making it a success. Thus, the project itself could increase the cohesiveness between your units and departments that traditionally do not work together. Cons Significant IT resources will have to be dedicated to this project for many years, because this is not a one-time project new MU requirements are released with each stage. As regulations regarding Stage 2 demonstrate, in some cases, new regulations could affect previous rules. For example, hospitals attesting in federal fiscal year 2014 as their second or subsequent attestation year will have to follow new CQM that were released in the Stage 2 final rule. They might also need to capture additional and different data elements for the same measures previously used for Stage 1 attestation. 9 Additionally, hospitals may have to build patient-level electronic data files using the Health Level 7 (HL7) Quality Reporting Document Architecture (QRDA) standard for submission to CMS. Besides this, CMS and the Office of the National Coordinator for Health Information Technology (ONC) could provide corrections and changes to regulations as a part of their ongoing improvement process. With an internal system, you must certify your solution on your own. The cost and effort of certification could be high and would have to be repeated with each MU stage. Furthermore, the organization s internal teams may lack knowledge of MU s many closely intertwined clinical and IT requirements. This opens the door to potential misunderstanding or misreading of regulations, creating costly mistakes. Questions to Consider Do you have the expertise in house that can build solutions using the standards some complicated (e.g., HL7 QRDA) included in MU regulations? Do you have a good track record of your technical and clinical teams working together on complex projects? Can you muster enough internal engagement from future users? What happens if one of your key technical or clinical experts leaves the company in the middle of this project? Do you have enough understanding to go through the certification process? Beyond Modular Electronic Health Records 5

This approach allows you to retain trusted solutions that work best for different divisions and specialties within your HCO. Option 3 Bridging the Gap Solution This option involves finding a vendor with a solution that can bridge the gap between all current systems and provide reporting for MU CQMs. Pros This approach allows you to retain trusted solutions that work best for different divisions and specialties within your HCO. After all, you already spent significant time selecting and implementing various systems. Your users know how to utilize them and have established workflows around them. There will be no loss of functionality. It s possible that some new workflows will have to be established, but they are minimal compared with the workflows and retraining efforts needed for Option 1. This option requires no costly upgrades for either software or hardware, and it continues to provide you with the flexibility to negotiate new licenses, perform upgrades, or even occasionally replace an out-of-date application. The vendor providing the MU CQM solution would be responsible for staying on top of the latest regulations and changes necessary to continue to meet CQM reporting requirements. The vendor, if they have the appropriate experience and a long-term vision and strategy, may be able to provide a solution that becomes the de facto system for your hospital s clinical quality reporting and performance improvement needs. If the vendor providing a bridging solution is not able to meet future MU stage requirements, the pain of replacing MU CQM reporting solution will be much less than with an all-in-one solution, which would require a total overhaul of your IT system. While implementing a vendor solution, you will be working with experts in MU requirements and getting the support you need in this complex process. Your vendor should be able to guide you through your attestation process. Cons This solution requires dealing with multiple vendors (for the retained solutions and the bridge solution). But if you already have an established process for this, it should not be a serious issue. Questions to Consider Do all or most of your current applications meet your needs? Do your nursing staff, IT staff, and physicians have a high tolerance for change? Do you already work with a trusted vendor that has a solution to bridge your current systems? Does this vendor have a good track record, indicating a serious commitment to meet future MU certification requirements? How much can you spend on this vending solution, considering the cost of any other changes needed for overall MU requirements? 6 Beyond Modular Electronic Health Records

Choosing a Solution With MU attestations ongoing since early 2011, we now have access to healthcare industry trends on what IT solutions HCOs are choosing for meeting MU goals. Data released in April 2012 by CMS on MU Stage 1 attestations that were completed by both eligible hospitals and eligible providers between April 2011 and January 2012 10 show that most attested HCOs opted for either Option 1 or Option 3 solutions. The dataset contains information on 59,923 attestations by eligible providers, with 1,953 completed by hospitals. The attestation numbers are based on the certified technology in use. Thus, if an eligible hospital used modular EHR technology from four vendors, the data show four separate attestations. Of the hospital attestations: 787 completed attestation using one complete EHR system 610 completed MU attestation using modular EHR systems Figure 2: Modular EHR vs. Complete EHR Attestations Completed Attestation Using Modular EHR 44% Completed Attestation Using Complete EHR 56% Source: The Department of Health and Human Services Office of the National Coordinator for Health Information Technology This breakdown shows that a majority (56 percent) of hospitals committed to one vendor. The other 44 percent of 2011 hospital attestations were completed using EHR modules from different vendors, giving them the flexibility to replace a single module without going through a complete system overhaul. For these, the number of systems used varied widely. The typical number of modular EHRs utilized by one hospital was three, while the most used was 14. Considering carefully the pros and cons outlined above and adding some of your own is a must. Taking into account the cost of each solution is critical; with any big purchase you will encounter hidden costs. For example, the cost of training is not limited to how many hours your nursing staff will attend training, but also includes the hours of staff performing the training, printing training materials, supplying or renting facilities big enough to hold training sessions for large audiences, etc. Making sure that you have the right people at the table making this assessment is another must. Truven Health has been helping clients meet various federal and state government reporting requirements since providers began using administrative data to support financial and operational decisions in the 1980s. Traditionally, our reporting clients represent the quality assurance teams. However, we noticed that for MU reporting engagements, it is crucial to have IT representatives at the table. But having IT alone does not provide the clinical and workflow expertise needed to successfully complete the project and meet the MU CQM attestation requirements. Beyond Modular Electronic Health Records 7

Working hand in hand, clinical quality assurance and IT can fully assess which route will produce the best results for their particular organization. Creating a Team That Works To meet their MU CQM reporting goals, providers need to successfully blend technical (in particular, IT) skills with clinical knowledge. When these two skill sets are not present in equal amounts, the process of meeting MU requirements often grinds to a halt. Unfortunately, creating this balance can be complicated and frustrating. Different departments, divisions, and groups within HCOs tend to function independently. Reaching MU goals requires a fundamental change in the ways HCOs are used to working. Many clinicians and clinical quality assurance personnel first see an MU project as an IT initiative after all, it is aimed at speeding up the adoption of various technologies in healthcare. And with MU requirements being heavily centered on implementing certified EHR and other software applications, many IT departments support the clinical community view that IT should be in charge of MU projects. But in addition to often being understaffed, hospital IT groups may not be familiar with other healthcare regulations related to CQM reporting. For example, MU CQMs sound very similar to core measures that HCOs are used to reporting on to CMS and the Joint Commission. But close examination of MU CQMs shows that even though they have the same names and are aimed at assessing the same clinical measures, they go about it in different ways, looking at radically different data points. Lacking this understanding could be crucial to your ability to successfully report on MU CQMs. The MU legislation is a game changer. As the MU rule attempts to strike a balance between the urgency of adopting EHRs to improve healthcare and the recognition of the challenges that this adoption will pose to HCOs, 11 a balance should exist between the transformation efforts of clinicians and IT personnel. To create the stakeholder buy-in on all sides: 1. IT staff should see this as their opportunity to provide feedback and participate equally in the decision-making process. 2. Clinicians and quality assurance should feel that they are getting a solution that will help them improve clinical outcomes. 3. Administrators should understand the value they will get from new systems and changes helping them to deal with such items as pay-for-performance measures. To successfully implement a CQM reporting solution and other MU-related software applications, as well as the new workflows and processes that come with them, clinicians and IT staff will be most successful if they work as partners. In fact, the stage approach to the MU requirements, where a bar is significantly raised with each new stage, will require ongoing engagement to meet these changing requirements. 12 8 Beyond Modular Electronic Health Records

Figure 3: Meaningful Use Stage Approach Data capture and sharing Advanced clinical processes Improved outcomes Source: Centers for Medicare & Medicaid Services Working hand in hand, clinical quality assurance and IT can fully assess which route will produce the best results for their particular organization, setting the stage for a long-term strategy for the future stages of MU. Interestingly enough, the latest data available on new EHR purchasing and EHR replacement indicates that this has been a learning process for a lot of HCOs. As reported by HITECH Answers in May 2013, the percent of EHR replacements went from 10 percent in 2010 to 31 percent in 2013, with more than 60 percent reporting dissatisfaction with their current EHR as the main reason. 13 Beyond Modular Electronic Health Records 9

Figure 4: Reasons for Replacing EHRs Dissatisfied with current EHR Want a fully integrated system Old/unsupported system Cost implications Compliance/Meaningful Use See what else is out there Poor customer service Deployment concerns Dissatisfied with billing application 0% 20% 40% 60% 80% 100% Percent of Respondents Q1 2012 Q1 2013 Source: Fried D. Four Years Later: Impact of the HITECH Act on EHR Implementations. HITECH Answers. May 28, 2013. Looking Forward For the best possible MU CQM results, you must create the right partnerships within your organization and with selected vendors. When choosing a system, look forward. Ask yourself whether this solution has the potential to address more than your current MU needs. For example, could it help automate data collection and reduce manual abstraction currently needed for various federal- and state-mandated reporting thus shifting the focus from collecting and sending the data to evaluating CQM results allowing you to continuously improve quality of care? Taking this a step further: Does the same vendor have only a standalone application you need this minute or a suite of solutions that potentially could address issues that are already on your horizon such as a patient portal required for MU Stage 2, healthcare analytics, or bundled payments? Addressing this challenge, and at the same time creating a long-term vision for your HCO, will help you avoid silos within your organization and connect the dots across primary care and specialties, resulting in better quality of care for your patients. 10 Beyond Modular Electronic Health Records

References 1 Gans D, Kralewski J, Hammons T, Dowd B. Medical Groups Adoption of Electronic Health Records and Information Systems. Health Aff. 2005; 24 (5): 1323-1333 2 Executive order issued by President George W. Bush on August 22, 2006: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs. http://archive.hhs.gov/ valuedriven/federal/index.html 3 Ralf-Gordon J. US $ 1.3 billion: The market for mhealth applications in 2012. research2guidance. January 25, 2012 http://www.research2guidance.com/us-1.3- billion-the-market-for-mhealth-applications-in-2012/ 4 Weinstock M. 2012 Most Wired. Hospitals & Health Networks Digital Magazine. July 7, 2012. http://www.hhnmag.com/hhnmag/jsp/ articledisplay.jsp?dcrpath=hhnmag/article/data/07jul2012/0712hhn_ Coverstory&domain=HHNMAG 5 Conn J. EHR incentive payments reach nearly $12.7B. Modern Healthcare. April 2, 2013. http://www.modernhealthcare.com/article/20130402/news/30 4029952?AllowView=VW8xUmo5Q21TcWJOb1gzb0tNN3RLZ0h0MWg5SVgr a3nzrzror3l0wwrmwgjvudberwxinutpqzmywmv2ntm0wupibwo =&utm_source=link-20130402-news-304029952&utm_medium=email&utm_ campaign=hit 6 Allscripts Protests After Losing Bid for Health IT Project in NYC Hospitals. ihealthbeat. October 11, 2012. http://www.ihealthbeat.org/articles/2012/10/11/ allscripts-protests-after-losing-bid-for-health-it-project-in-nyc-hospitals. aspx#ixzz2fketh3nw 7 WakeMed News Releases. WakeMed to Invest in Comprehensive Medical Records Solution. November 14, 2012. http://www.wakemed.org/body.cfm?xyzpdqabc=0& id=247&action=detail&ref=277 8 Medicare and Medicaid Programs; Electronic Health Record Incentive Program Stage 2. Federal Register. Vol. 77 No. 171. September 4, 2012. http://www.gpo.gov/ fdsys/pkg/fr-2012-09-04/pdf/2012-21050.pdf 9 Ibid. 10 The Office of the National Coordinator for Health Information Technology. CMS Medicare and Medicaid EHR Incentive Program Electronic Health Record Products Used for Attestation. http://www.healthit.gov/sites/default/files/pdf/ HealthDataGov%20MU%20Attest%20Fact%20Sheet.pdf. Note: This dataset merges information about the CMS, Medicare and Medicaid EHR Incentive Programs attestations with the Office of the National Coordinator for Health IT s Certified Health IT Products List. 11 DeGaspari D. Stage 2: New Challenges Emerge as CMS Raises the Bar. Healthcare Informatics. August 28, 2012. http://www.healthcare-informatics.com/article/ stage-2-new-challenges-emerge-cms-raises-bar 12 Raiford R. and Copoulos M. Meaningful Use Stage 2: Raising the Bar with Exchange, Standards, Engagement. IHealthBeat Perspectives. March 15, 2012. http://www.ihealthbeat.org/perspectives/2012/meaningful-use-stage-2-raising-thebar-with-exchange-standards-engagement.aspx 13 Fried D. Four Years Later: Impact of the HITECH Act on EHR Implementations. HITECH Answers. May 28, 2013. http://www.hitechanswers.net/four-years-laterthe-impact-of-the-hitech-act-on-ehr-implementations/?goback=.gde_4400043_ member_24477035 Beyond Modular Electronic Health Records 11

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