Dr. Kleeberg Goes to Washington to Discuss the Consequences of a “Reboot”

Paul Kleeberg, MD, REACH Clinical Director for Minnesota and North Dakota

Last April six senators led by Sen Thune (R-SD) sent a letter to Secretary Sebelius expressing concern that the money being spent on the EHR incentive program was not money well spent.  They detailed these concerns in a white paper called “REBOOT: Re-examining the strategies needed to successfully adopt IT”.

Among their concerns were that the program:

• Lacked a clear path toward interoperability
• Payments were made without evidence of meaningful use
• EHRs were increasing the ordering of unnecessary tests and increased billing
• Provided inadequate safeguards to protect against fraud and abuse
• Does not require providers to demonstrate their technology is secure
• Does not assure sustainability with penalties hitting providers, especially small providers
• Created a patchwork of overlapping reporting requirements

The white paper was part of a broader effort to solicit feedback from the administration and the provider community about the incentive program.  Some of the info in the white paper is accurate while some was misguided or inaccurate.

Sometime the week of July 1, the HIMSS Government Relations and our Institute for eHealth Policy were asked by lead staff of the “Reboot Group” to convene a series of closed-door bipartisan Senate staff briefings so that they could prepare for what are likely to be at least three upcoming Senate Finance hearings on the status of HITECH. The hearings will start on July 17th with ONC and CMS as witnesses.   The first briefing was scheduled for July 10th.  HIMSS arranged for me as HIMSS Chair-elect and head of the North Dakota-Minnesota Regional Extension Center (REACH) to brief the group along with Elliot Sloane, Ph.D. an expert on data standards and co-chair of the IHE (Integrating the Healthcare Enterprise) International Standards body and Janet Marchibroda, Director of Health Innovation at the Bipartisan Policy Center.  This briefing was attended by 36 Republican and Democratic Senatorial staffers.  The three of us updated them on what the incentive program has been able to accomplish and the data that show the program has clearly driven the adoption of electronic health records.  We also pointed out that the interoperability standards that are required for Stage 2 will include the ability and requirement to exchange patient information across silos of care.  Finally we described how reporting requirements are being harmonized allowing providers to report once and satisfy several programs.

We also highlighted a number of concerns.  One is the growing disparity between the rural and the urban/suburban.  Many of the larger systems that had adopted EHRs before the creation of the incentive program have seen clinical and financial benefits.  Their products have had years to mature and these facilities have had years to compile patient data and redesign their workflows.  These factors have made it easier for them to get the benefits of EHR use and to achieve meaningful use.  For most of the hospitals in rural communities, it is a different story.  Many are only now beginning to use EHRs and many of the products designed for small hospitals are not as mature as those in larger systems.  We also pointed out that small hospitals do not have the IT staff of a large system and that their geographic isolation creates a barrier for them to find the staff and resources to necessary to implement and optimize the use of an electronic health record.  We urged that they pay attention to the needs of these communities in order to not further deepen the digital divide.

We also made it clear that to “reboot” now would derail a program that was clearly headed to the interoperability goals that some of the senators did not believe were in 2014 certified software and Stage 2 requirements.  Meaningful Use requirements come in phases and each release is timed so as to learn from the previous phase while allowing enough time for vendors to enhance their software and time for providers to adopt the software for the next phase.  This “course correction” is built into the current incentive program negating the need of a “reboot.”

Finally, we expressed our concern for the providers who, through no fault of their own, have been unable to implement certified software.  Some hospitals have encountered long waiting periods, and recently, some hospitals have seen their promised upgrade schedules for 2014 certified software be delayed indefinitely by their vendor.  Though they may be able to apply for a hardship exemption so as to avoid the penalties, these facilities will lose out on the incentive designed to assist them in the cost of implementation and will no longer have access to the subsidized technical assistance from a Regional Extension Center.  This issue will also need their continued attention.

In all, it was a great experience and great opportunity for which I am grateful.  Thanks to the HIMSS staff responding so quickly to the request, we were able to make 1/3 of the senate offices aware of the value of the incentive program, why it should continue and, at the same time, make them aware of some of the issues that will need continued attention.

What You Need to Know about the MEIP 12 Month Rolling Qualification Period

Reid Haase, REACH HIT Consultant

As many eligible providers (EPs), eligible hospitals (EHs), and critical access hospitals (CAHs) move into year two of the MN Electronic Health Record (EHR) Incentive Program (MEIP), participants are required to qualify for the program annually, in part, by calculating their minimum patient volume (MPV). The MPV has, to this point, been calculated during a chosen 3-month period within the prior calendar year for EPs or the prior fiscal year for EHs and CAHs. For EPs, the threshold for MEIP qualification is 30% of all encounters (20% for pediatric providers) and 10% for EHs & CAHs. With the release of the Stage 2 rule last August, states were given the latitude to also allow a 12-month 'rolling' period as an option along with the 12 month prior calendar or fiscal year. MN opted for, and was granted, the ability to do the new 12-month 'rolling' period as of January 2013. Note that this change can also be utilized by clinics doing a group EP, rather than individual EP qualification.

Program participants can choose either the 12 month prior calendar or fiscal year or opt for the 12-month 'rolling' period which ends the month prior to the month in which they attest. Example: An EP wishes to attest to his/her second year in October 2013. The chosen MPV 30% period could occur in calendar year 2012 or between October 1st, 2012 and September 31, 2013.  An advantage of this rolling 12-month period could be for EPs that recently joined a practice and would otherwise not have the minimum encounter volume. An EH/CAH example of why this would be beneficial would be for those organizations that might not meet the 10% threshold in the prior fiscal year, but were able to meet or exceed 10% when looking at a rolling 12-month period with more recent encounter data.

MPV references (see the first and second bullets on page 67)

Provider Eligibility: Patient Volume Calculation
90-day period for Medicaid patient volume calculation:

• Under Stage 1 rule, Medicaid patient volume for providers calculated across 90-day period in last calendar year (for EPs) or Federal fiscal year (for hospitals)
• Under Stage 2 rule (applicable to all stages), States also have option to allow providers to calculate Medicaid patient volume across 90-day period in last 12 months preceding provider’s attestation
• Also applies to needy individual patient volume

Have we finally turned the corner toward meaningful patient engagement?

Jennifer Lundblad, President & CEO, Stratis Health

Over the past decade, there has been a lot of talk about consumerism and engaging patients and families in health care. Yet many clinicians, health care organizations, and patients have not had the knowledge and resources (and in some cases, the motivation) to know how to move forward.

Now, we are finally turning that corner. A number of things are converging which indicate the shift toward patient engagement is underway…

Health care delivery organizations are beginning to have some of their payment based on how well their patients perceive their care to be; the most powerful example of this is CMS’ Hospital Value-Based Purchasing Program, launched last year, which rewards hospitals for excellent performance, of which the HCAHPS (Hospital Consumer Assessment of Health Care Providers and Systems) score comprises nearly one third of the total performance rating for a hospital. In addition, the current EHR Meaningful Use stage 1 criteria include items that emphasize the importance of patient engagement, including requirements for an after visit summary for patients after each health care encounter. More focused and intense requirements are anticipated in Stage 2, including online access for patients to their information

Beyond payment and requirements, we are seeing and reading more and more about patient engagement. It is striking and timely that the entire February 2013 issue of Health Affairs is devoted to patient engagement…entitled “New Era of Patient Engagement.” Articles and topics range from shared decision making, to the linkage between patient activation and health care costs, to new models of more patient-centered care delivery.

It is an exciting time to be working to improve quality in health care, and to reach the long overdue turning point toward patient engagement as the next “blockbuster drug.”

2014 EHR Certification – Will all vendors stay the course?

Phil Deering, REACH Regional Coordinator/HIT Consultant

As one of REACH’s Regional Coordinators I sit at a nexus of consultant/client activity. So I hear lots of “chatter” about meaningful use, EHRs, workflows, etc. One of the REACH consultants forwarded me the following (heavily de-identified) email:

We received notice from (our EHR vendor) on 1/31/13 that they are sun setting our product. They will discontinue development on 6/30/13 and they will discontinue support 6/30/14. Needless to say we have to start looking for another EHR/PM. Lucky us, huh? ….. Never a dull moment in healthcare!

The vendor didn’t say so, but it’s reasonable to expect that the requirements for 2014 EHR Certification that have emerged as part of the Stage 2 final rule have caused this vendor to close up shop.

To be a certified EHR in 2014, vendors will need to meet a large number of new requirements including 15 that are completely new (provider notes, family health history, access to images, view, download and transmit information to 3rd parties, safety enhanced design and data portability to name a few) and 23 revised criteria. Given the stringent new requirements, it is not surprising that some vendors would get out of the business.

On the other hand, features of 2014 Certified EHR Technology actually invite innovation and encourage niche vendors to get into the market. Those features are the new modular design of EHR’s the 2014 specification allows and the requirement of data portability. All EHR’s must have base functionality that ensures safety, quality and exchange of data. However, with 2014 rules, an EP does not need to purchase technology that has features the EP doesn’t need in their practice. So, for example, a dentist could purchase an EHR that doesn’t have immunization registry upload. This is good for dentists (they don’t need to buy features that they don’t use) but also good for niche vendors (they don’t need to build or charge for features their customers won’t use). Data portability will make it easier for information to be passed from one EHR to another allowing for this modular construction and lowering the bar for migration from one vendor to another. 

Predicting the future is dangerous, but it’s my opinion that the 2014 certification requirements will result in additional choices for specialists, at the same time, we may see fallout among the small soup-to-nuts vendors that appeared in such great numbers at the beginning of the push for MU.

For a comprehensive review of the final rule on 2014 CEHRT  read this document prepared by CHIME.

Power of Collaborating in Reaching and Maintaining MU

Sarah Tupper, MS, RN-BC, LHIT, CPHIMS, REACH HIT Consultant

Are we born wanting to collaborate? I don’t think so. Most infants I have known are pretty self-centered (which is totally appropriate). I don’t think my houseful of teenagers is as collaborative as they were when they were in elementary school, either. So, based on my own experience, I would say, no, that the appreciation for, and desire to collaborate comes with experience. Some people naturally prefer to work in groups, while others prefer solitary work. Collaboration is different. Collaboration refers to working together, or jointly to accomplish a shared goal. I believe that part of becoming more and more collaborative is realizing and appreciating that others have gifts that I am not blessed with and never will be, and I certainly would want them on my team if we couldn’t be successful without their particular gift! I believe that in order to be a true collaborator, one has to become humble, and admit, that indeed, there isn’t much that I can accomplish all by myself.

As I write this, a couple of sayings come to mind: “a cord of three strands is not easily broken”, or “two (people) are stronger than one”. For the past two years, I have had the privilege to facilitate a collaborative group through REACH. The participants are similar in organizational size, are located geographically close to one another, and they share the same EHR vendor. This group has been through a lot together…implementation of their EHR, working through snags in the meaningful use (MU) reports out of their EHR, sharing workflow “a-ha’s” as they worked toward meeting the MU objectives. They have even visited each other’s sites to observe workflows, report set-up, and other sharing. There was a time when this group was able to persuade their vendor not to charge extra for a piece of functionality that was needed to meet MU. They were successful! They shared a common goal, set forth to achieve it by leveraging the expertise of each individual, and collectively, although small, they continue to be mighty in their achievements. Now, that’s collaboration!

I believe that the outcomes of this group would not have reached the level they have without the amount of collaboration they have enjoyed and been willing to maintain. I assumed that this group might want to disband after the majority of the participants successfully attested to their first 90 days of Stage 1 MU. Instead, the group decided to continue to collaborate, just less frequently. I believe that strong bonds are formed and will be naturally maintained when people successfully collaborate through challenging situations. It reminds me of my days practicing as an RN in acute care. The clinical situations that had the best outcomes were those where all involved (the patient, nurse, respiratory therapist, physical therapist, occupational therapist, pharmacist, physician, dietician, family members, spiritual care) humbly admitted that they couldn’t save the patient on their own, rather, they “pooled” their special areas of expertise and life experience, collaborated to plan, intervene, and support a common goal: assisting the patient to a higher level of functioning. That’s when collaboration can make the difference between life and death! For more stories about the power of collaboration to meet MU, I recommend a visit to the HealthIT.gov website.

The 8 Commandments of Meaningful Use Penalties for Eligible Professionals

Phil Deering, REACH Regional Coordinator/HIT Consultant

No one I know, or can imagine knowing, has time to read all the blogs, tweets, and other forms of information that address meaningful use. However, there is a lot of great information to be had in the blogosphere. Jim Tate, a frequent blogger on HITECH Answers has been an authoritative source, who keeps information interesting and pithy. I found his recent post, The 8 Commandments of Meaningful Use Penalties for EPs, to be really useful. REACH would love to hear your thoughts on it as well.

HIT Evolution and Meaningful Use Stage 3: From Finance IT to Patient IT

Joe Wivoda, REACH HIT Consultant

The evolution of information technology (IT) in health care has been remarkable, and very similar to what other industries experienced in the 1980's and 1990's. Health care is definitely behind manufacturing, banking, education, and other industries when it comes to using IT, but we can learn from those industries to (hopefully) leap ahead. The new Meaningful Use Stage 3 Request for Comment made me realize that IT professionals working in health care should perhaps consider this and begin to call themselves Patient Information Technology workers instead.

Meaningful Use Stage 1 started the trend with the requirement that hospitals and clinics provide patients with an electronic copy of their health information upon request. Funny thing is that few people requested it! Medical Record staff did not make it a clear option for patients requesting their information, and staff did not realize the data was displayed in a user-friendly way. It was okay to provide patients with a paper copy of their chart, but some organizations decided that it was necessary to encrypt their electronic copy. This is a misunderstanding, and provides yet another barrier to engaging patients in their care.

Stage 2 took a new approach to patient engagement: Portals and Personal Health Records (PHRs). Not only do half of the patients need to be set up in the portal or PHR, but 5% must actually access and use the information. Like it or not, we will need to get patients used to accessing their information online. Banks have been able to do it, and so have schools, car dealers, and just about every other industry. Heck, I know exactly when my UPS package arrives at my front door via an email, but it takes several days for a phone call from my physician to tell me my lab test was normal. UPS did not need a government-funded incentive program to begin to offer this service, they did it because customers asked for it and their competition was doing it.

The proposed Stage 3 measures that are currently out for comment take patient engagement even further. Patients will have to have the ability to request amendments to their records and submit patient-generated information. By 2014 I expect there will be blood glucose monitors that connect to your smartphone that will automatically update a designated portal or PHR. Imagine the benefits to patients! Imagine the concerns from providers ("How do I know that is accurate?").

Health Care IT professionals need to take a lead role in creating excitement around patient engagement technology. Until recently, HIT was primarily Finance-IT, and with meaningful use it has finally become true HIT, but I argue we need to be Patient-IT. If we take a patient-centered approach to everything we do in IT we will make a real impact on the health of patients. If we took a patient-centered approach wouldn't the bills be easier to understand for the average patient? If we took a patient-centered approach wouldn't there be a portal that was user-friendly? Wouldn't we have a help desk for patients to call to get help in understanding how to log in and understand their information? Wouldn't we have higher quality, safer, more efficient processes if we put the patient at the center of our implementations and not the physicians and staff?

Starting today I am going to consider myself a Patient Information Technology worker. It will take a while for me to get used to calling myself that, but I will start today. Will you join me?