Beacon Partners Meaningful Use Analysis and Recommendations Report

A RoAdmAp towARd oRgAnizAtionAl ReAdiness

AuthoRed by Kevin R. Burchill, Esq., FACHE, Director Jay M. Tolchinsky, Director of Marketing and Communications contributing Authors: Sharron Finlay, Regional Director Alan Worsham, Vice President

AnAlysis And RecommendAtions RepoRt

AnAlysis And RecommendAtions RepoRt

meAningFul use A commentARy On the eve of the new year, the Department of Health and Human Services (HHS) issued a just-in-time and greatly anticipated release announcing the regulations required to implement health information technology (HIT) as stated in the provisions of the American Recovery and Reinvestment Act of 2009 (ARRA). The Office of the National Coordinator (ONC) and the Centers for Medicare and Medicaid Services (CMS) released the proposed rules for the standards, implementation specifications and certification criteria, outlining Meaningful Use (MU) for Medicare and Medicaid Electronic Health Record (EHR) incentive programs. The proposed regulations have since been published in the Federal Register under EHR Incentive Program (CMS-0033-P) and lay the objectives and measures a healthcare organization (HCO) must meet in order to achieve MU in three stages. One yet-to-be-released regulation is the process for EHR certification; release is expected in 2010. A Meaningful EHR User is defined as an Eligible Provider (EP) and an Eligible Hospital (EH) that meet the following requirements within the specified payment year. 1. Use of a certified EHR in a meaningful manner.

A key component of an organizations ability to capitalize on the governments unprecedented EHR economic incentives is to achieve MU of its implemented technologies in a set, aggressive timeline. An organizations inability to reach these IT adoption usage goals will cost the organization significantly, not only in terms of potential revenue, but also improved patient care. The incentives and timeline may not work for many HCOs. The costs to purchase and implement the technologies will outweigh the potential incentives, but that should not deter an organization from continuing toward MU. Organizations may determine that they cannot meet the 2011 deadline and focus their strategy on doing it right the first time regardless of the federal timeline. The incentives present a one-time chance for facilities to recoup infrastructure investments in IT and quality reporting and must be seriously considered before penalties are applied in outer years. Regardless of the incentives the EHR journey is an organizations investment in quality, safety and patient care. After reviewing the regulations and hearing reactions within the healthcare community, it is clear that the rule is an ambitious and confusing set of regulations that most HCOs will have difficulties in meeting in the allotted timeline. Our industry as a whole, as well as vendors, will study these regulations, dissect the complexities of the three stages and determine whether the objectives and measures should, in reality, constitute an improvement in patient care.

2. Utilization of certified EHR technology that is connected in a manner that provides for the electronic exchange of health information to improve the quality of healthcare, such as promoting care coordination. 3. Submission of information on clinical quality measures and other measures in a form and manner specified by the Secretary.

YEAR OF ADOPTION
PAYMENT FOR ADOPTING BEFORE OR IN 2011 IF FIRST ADOPTING IN 2012: IF FIRST ADOPTING IN 2013: IF FIRST ADOPTING IN 2014: IF FIRST ADOPTING IN 2015:

2011 2012 2013 2014 2015 2016 2017

100% 75% 100% 50% 75% 100% 25% 50% 75% 75% 25% 50% 50% 50% 25% 25% 25%

PENALTIES BEGIN IF NOT ADOPTING BY 2015: THREE-QUARTERS OF THE APPLICABLE MARKET BASKET UPDATE IS REDUCED BY:

100%

100%

100%

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AnAlysis And RecommendAtions RepoRt

goveRnAnce And communicAtion From Beacon Partners perspective, the biggest challenge that we see for HCOs is their ability to develop and implement a patient care strategy supported by IT. An organizations readiness is key to support its patient care strategy and implement HIT. This requires the appropriate governance structure and leadership. Leaderships ability to develop and communicate the vision of the IT strategy will be the most important factor in the success of achieving MU. The communication strategy must include a robust change management plan that will leverage physician champions in support of the use of their technologies. The stages, objectives and measures will not mean anything if physicians do not understand and support the plan. History continues to prove this out. Do not be misled. Just because incentives are available, do not expect physicians to fall in line. inFoRmAtion technology consideRAtions On the IT side many physicians, hospitals and healthcare organizations have been on a journey toward an EHR for a number of years. The elements of MU define the specific requirements for the electronic record. In order to achieve MU within the timeframe (2011 through 2013), providers must re-assess their internal pace of IT adoption, consider the clinical transformation required and develop change and project management criteria to meet the requirements. For example, a so-called Year One or 2011 standard requires hospitals to meet a 10% level of all physician orders in a Computerized Physician Order Entry (CPOE) system; that level is 80% for physicians in their ambulatory setting or office. How will this be measured and what orders will qualify in the numerator and be part of the denominator are but two of the questions left unanswered during the 60- day comment period. Alignment Physician alignment is critical at multiple levels: it is a key driver of successful patient care strategy supported by an IT strategy; it dictates business growth from patient referrals; it makes compliance with safety and quality standards much easier; and, ultimately, physician alignment is a significant contributoror detractorto overall financial performance. Physician/hospital alignment is part of the health information exchange (HIE) standard in the later years of this legislation. These efforts are underway in various local marketplaces. Each HIE looks different, according to the data governance issues,

the relationships of EHs and EPs and the evolution of the marketplace. To establish one standard and measure all EHs and EPs against that standard is neither practical nor achievable. The level of sophistication of an urban academic medical center and its faculty practice physician group is likely different from a sole community provider hospital and its private practice medical staff made up of solo or small group practices. One size clearly will not fit all in attaining this element of MU. vendoR sustAinAbility Leadership must also work side by side with its chosen vendor to ensure that not only is the system CCHIT-certified, but that the vendor has a sustainable solution beyond 2015. How will the vendor react to changes in the regulations? Does the vendor have the bandwidth to meet your organizations timeline? Will the vendor understand the importance of workflow analysis as part of the implementation? Achieving MU will require extensive reporting from the vendor solution, especially in the area of outcomes. Historically, reporting is not a core strength for vendor solutions. We see further consolidation in the market over the next three to five years, so HCOs will need to choose their vendor solutions wisely. As HCOs consider vendor-based solutions, a proven track record of success in healthcare as well as a commitment to the HIT market space should be among the criteria utilized. pAtient Flow Hospitals function in discrete business units, each with its own unique patient flow, staffing and clinical standards. Lets focus on just two areas for illustration: Emergency Department (ED) and Operating Room (OR). EDs treat patients in an ambulatory setting based upon their triage, level of service and licensure. Many EDs are the front doors of their hospitals, with a large portion of admissions coming from the care received in the ED. It is not uncommon for more than 50% of the patients admitted to a hospital to come from its own ED and for more than 25% of the patients treated in the ED to be admitted. Each patient starts out as an ED registration and then can be converted to inpatient status when an admission order is written. How will the outpatient or ambulatory orders be counted? Treatment to admission and treatment to discharge are two common measurements in the ED. Each gets compounded with CMS and third-party payer observation status, where

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patients are housed in the ED, a holding area, or discrete observation unit for one to three days until their clinical progress has been ruled in or out for admission. In 4 to 6 to 23 to 72 hours in this non-admitted status, many orders will be written by physicians; how will they be counted? Similarly, OR patients within a hospital are often up to 75% outpatients. These same day cases require registration, documentation and treatment pre-surgically, intra-operatively and post-procedure in terms of recovery and ultimately discharge or, potentially, admission. In these settings, orders are documented by physicians (surgeons, anesthesiologists, residents/fellows). How will these be counted toward the 10% requirement if they remain a same-day surgical patient or even an overnight observation patient who is not admitted? We see the adoption of patient flow supporting technologies, such as CPOE, ePrescribing, Web portal technologies and clinical decision support as a substantive challenge toward attaining MU. QuAlity Quality reporting may be an easier standard for healthcare organizations to meet. CMS, The Joint Commission, various third-party payers and state health departments have required Core Measures or other clinical quality standards to be reported for a period of time. However, what is lacking is the uniformity of these measures or standards. Organizations must dedicate valuable resources to review records, document standards, establish reports and monitor results. As healthcare has moved from quality control to quality assurance to quality improvement, the counting, tracking, trending and reporting has gone from manual and labor-intensive paper chart review to reviewing a hybrid record of paper and electronic reports (some with faxed or scanned documents) to an EHR in the near term. The transparency of the results and reporting is a laudable goal to meet. The lack of one uniform standard for reporting must be addressed. hipAA / hitech Privacy and security updates under the Health Information Technology for Economic and Clinical Health Act (HITECH) provisions clearly bring the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standards initially established in a largely paper chart to an electronic record system. In addition to the standards, the penalties or fines have been more clearly defined. Since ARRA was signed on February 17, 2009, many HITECH standards have already been put into place. Healthcare organizations are still struggling to understand the legislation, have many unanswered questions about their organizational readiness and have no clearly defined federal office to which they can direct their questions or concerns. In addition to the federal standards, each state may have applicable laws or standards to consider. How will organizations be measured? With the applicability not clearly mapped and organizations still trying to understand their individual needs to update policies/procedures, audit tools, staff education and compliance and a host of other operational matters, we have our first publicized lawsuit brought by the State Attorney General in Connecticut. These laws need to be clearly defined to enact the changes that were sought. Subsequent years of the legislation will present additional, iterative standards for EHs and EPs to meet. An assessment must be made now, and plans for incremental changes in the future need to be considered for audit logs, employee training and the like. conclusion A recent study by Milbank Quarterly at the University College of London (UCL) identified fundamental and often overlooked tensions in the design and implementation of EHRs. The study was based on findings from hundreds of previous studies worldwide. Researchers concluded that depressingly, outside the world of the carefully-controlled trial, between 50 and 80 percent of electronic health record projects fail and the larger the project, the more likely it is to fail.

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A pAtient-CentRiC AppRoACh It is clear that the healthcare community is finally on the verge of adopting HIT as a way to improve patient care and quality. The next five to seven years will challenge an organizations leaderships ability to meet the ambitious timelines and transform the coordination of care through the exchange of patient health information (PHI). We view the exchange of PHI through the healthcare community as the key to outcomes management over the next five to seven years. The relationship between the healthcare process and outcomes management is not new; however, given the incentives, it carries a greater-than-ever importance. As the population grows and continues its portability, HCOs will need to manage the resulting effects on PHI. HIEs will play key roles in managing the hard to reach in the community and provide reliable outcomes that will enable clinicians to make decisions related to patient care. Effective usage of HIT will be the key factor in ensuring that the correct information is being provided for outcomes management. MU, objectives, measures, stages, incentives, while important, should not be the reason why the healthcare community is finally taking the adoption of HIT seriously. At the core of the healthcare community is the patient, who is dependent on the interrelationships within the community. Each of us in the healthcare community contributes to the patient experience, with those at the point of care held to the highest standards. The current government economic incentives are probably the most significant and important opportunities that your healthcare organization has ever had to improve operations and patient care through the use of IT.

Individual physicians, multi-specialty group practices, hospitals and health systems all have been on the EHR journey in recent years. The federal stimulus incentives are offering a unique opportunity to accelerate the adoption of this technology and provide vital resources for clinical transformation efforts. Right now, its about pace and organizational readiness and the avoidance of the speed bumps on the journey. What is the pace of adoption already underway in your organization? Speed Bump: Lack of physician alignment and participation can lead to an implementation failure. What organizational, IT and facility projects need to be prioritized to meet MU? Speed Bump: An outdated organizational strategic plan leads to confusion of priorities based upon prior facility planning paradigms. How will you govern your ARRA strategy across all levels of your organization? Speed Bump: Leaderships not being fully invested in the plan will lead to organizational chaos and lack of MU attainment. How can your clinical teams come together with your medical staff to support these systems? Speed Bump: Physicians viewing the hybrid record as pure nursing documentation and not relevant to their patient care needs. What is your HIE alignment plan? Speed Bump: Community physicians could align with competition, resulting in lost market share. How will you review your vendors solution vs. CCHIT certification? Speed Bump: Vendors solution does not support your vision or worse, vendor does not have a sustainability plan or may not continue in the healthcare market place. Is the HIMSS EMR Adoption Model relevant to the objectives and measures? Speed Bump: Lack of compliance due to competing standards

And, if you need one more reason, it is the right thing to do for patient care, quality and safety. The Road Map for MU has now been established. Organizations have begun to absorb the proposed rule published in the Federal Register on January 13, 2010, develop and assimilate their plans and go back to their IT strategic plans, multi-year and rolling capital and operating budgets and organizational

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transformation and workflow re-design needs to be assessed in light of the 2011 through 2013 timeline to receive maximum incentive funding under the stimulus program. EP and EH processes have been established, and the certification process is to be formalized. So, the rubber has hit the road, and its time for the roadmap. Internal structures must be formalized around executive sponsors, projects teams, charters, scope and measurable milestones/deliverables, each with an eye on meeting MU and doing so within the prescribed timelines. For example, on CPOE efforts hospitals need to assess their best paths to meet the current 2011 standard of 10% utilization for orders. Multi-disciplinary teams need to support medical providers as the online documentation moves away from the current model that is largely based on just nursing notes and results reporting. structures to re-adjust their tactical plans over the next critical 12 to 18 months. The sweet spot to receive full funding is well known: 2011 through 2013. We advise Beacon Partners clients to complete a Readiness Assessment (RA) that takes into account the following items. stRAtegy Every good patient care strategy begins with an idea and is supported by a source document. Start by looking at your governance structure and identify your business and legal risks up front. Are there risks that you can assume, others that you will want to insure against and still others that you would be willing to contract away? Where your governing board rests on these issues will provide the starting point for senior leaderships road map. MU adoption, at the macro level, entails information technologies around EHRs, quality reporting, privacy and security and HIE capabilities. The governing bodys fiduciary responsibility clearly rests across the financing of these plans, quality and safety matters within your organization, protecting PHI on behalf of the community that you serve and ensuring the structure by which information is pushed out to and pulled back from physicians, patients, payers and other providers. So, start there for your Readiness Assessment (RA) and be forward-looking in your approach to achieving MU. Your RA needs to look beyond the four walls of your organization and include key relationships, clinical linkages and strategic alliances as you plan for HIEs. Think through ownership, control, access and security needs now as you build your data repositories or warehouses. stRuctuRe The pace of your organizations current IT plans, clinical Physician champions or project sponsors need to be identified, promoted and touted as early adopters of this technology. Organizational readiness and project management skills need to dovetail with good old-fashioned politics and public relations. You cannot succeed otherwise. It is not an either/or issue; it must be a both/and proposition. Details right down to nursing station redesign needs, equipment configuration (computers on wheels or rovers, scanners, FAX machines, workstations, tablets) and areas for charting and dictation stations add to the sum that will assure future successes. systems With the acquisition and adoption of IT, the real work for an organization or physician office truly begins. Your patient care strategy requires that it be supported by a system that is certified. It is important to take a holistic approach to the changes required and to step back and reflect on the improvements in patient care, clinical documentation, improved quality and increased safety that will result from these work efforts. That must be embedded in the charter and drawn on frequently, as clinical transformation and changes begin. Understanding your current workflows (documenting in detail with flowcharts and process flow schemes) is the first step to a successful change management process for IT adoption. Measurement of current processes will assist with objections in the rollout. For example, understanding how long it takes for a physician to review a patients record, see a patient at the bedside, complete notes and write a series of orders for medications, tests and consultations is a foundation essential. On routine rounds, how do physicians see their patients? There are typical and distinct patterns.

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Physicians find their primary nurse, gather charts/records and head off on rounds. They review the chart, visit with the patient and family and chart their observations and orders while sitting in the patient room or at a convenient charting sub-station nearby. Then, they move on to their next patient. They tend to work linearly. Physicians go to the nurses station, find a chair and their charts to be reviewed and make notes on each of their patients before going to see them individually. After seeing each patient, they jot down additional care plans. After rounding on all of their patients, they return to a charting or dictation area to write their orders and notes. They tend to work sequentially.

sAvings It may be easier to quantify the hard costs of a new system than to catalog the soft savings as a result of a successful implementation. Whether you look at Return on Investment (ROI) or Total Cost of Ownership (TCO) models, under the stimulus incentive payments, you will have actual dollars to measure against. In addition, there are real cost avoidances seen with the prescribed civil penalties under HITECH/HIPAA. With ranges from $100 to $1.5M, it is easy enough to document the need to look at your privacy and security policies and procedures. Finally, quality reporting already has been measured by CMS in their Value Based Purchasing (VBP) programs, a/k/a pay-for-performance (P4P). Physicians have already been able to receive additional funds for ePrescribing (eRx) and quality reporting (under PQRI). The savings are there to offset the investments. In summary, the MU Road Map will be a challenge that organizations can successfully traverse with proper pre-planning, organizational support from the governance level on down and effective project management. The destination is improved clinical care and patient safety.

A potential solution for the first type of physician would be a tablet. A potential solution for the second type of physician is a space sufficient for online charting with a suitable number of devices for access. You need to know how long their rounds take now; before you ask them to trust you that speed will even out after new system adoption and with a level of proficiency in a short period of time. Dont short-change this upfront opportunity to understand the workflow of primary care, specialists, hospital-based physicians, etc. Getting general buy-in and understanding at this point will greatly improve the support system and staffing required after Go-Live.

2010 Beacon Partners, Inc.

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