Not so mean­ing­ful for some

Crit­i­cal-ac­cess hos­pi­tals seek more clar­ity from feds

Modern Healthcare - - Information Edge - Jes­sica Zig­mond

As health­care providers di­gest HHS’ “mean­ing­ful use” reg­u­la­tions, the ru­ral health com­mu­nity ex­pressed con­cern last week that the def­i­ni­tion lacks clar­ity for crit­i­cal-ac­cess hos­pi­tals. Mean­while, a coali­tion of ru­ral and health in­for­ma­tion tech­nol­ogy leaders of­fered rec­om­men­da­tions to help ru­ral providers man­age per­haps an even greater prob­lem: health IT work­force chal­lenges.

Just a day af­ter HHS an­nounced its two reg­u­la­tions—which to­taled nearly 700 pages com­bined—Louis Wen­zlow, chief in­for­ma­tion of­fi­cer at the Ru­ral Wis­con­sin Health Co­op­er­a­tive, ad­dressed the is­sue of mean­ing­ful use in his blog. In the en­try, he writes that the pro­posed rule for the elec­tronic healthrecord in­cen­tive pro­gram un­der the Amer­i­can Re­cov­ery and Rein­vest­ment Act of 2009, also known as the stim­u­lus law, ex­cludes crit­i­cal-ac­cess hos­pi­tals from Med­i­caid in­cen­tives.

“Nu­mer­ous stud­ies have in­di­cated that CAHs have sig­nif­i­cantly lower EHR adop­tion rates than gen­eral hos­pi­tals, as well as great bar­ri­ers to EHR im­ple­men­ta­tion, in­clud­ing lack of cap­i­tal, min­i­mal HIT staffing lev­els, and re­duced EHR sys­tem” re­turn on in­vest­ment, Wen­zlow writes. “CAHs with high Med­i­caid uti­liza­tion rates are likely to face even greater chal­lenges than other CAHs, let alone gen­eral hos­pi­tals.”

The rea­son that the CMS ex­cluded crit­i­calac­cess hos­pi­tals, Wen­zlow ex­plains, is be­cause the stim­u­lus law states that el­i­gi­ble Med­i­caid providers in­clude chil­dren’s hos­pi­tals and acute­care hos­pi­tals that have at least 10% Med­i­caid vol­ume. Ac­cord­ing to Wen­zlow, crit­i­cal-ac­cess hos­pi­tals have al­ways con­sid­ered them­selves to be acute-care fa­cil­i­ties—even though they are not classified as such by the CMS—as their in­pa­tient ser­vices are for acute care, al­though lim­ited to 25 beds.

Brock Slabach, se­nior vice pres­i­dent of mem­ber ser­vices for the Na­tional Ru­ral Health As­so­ci­a­tion in Kansas City, Mo., says crit­i­cal-ac­cess hos­pi­tals are usu­ally “fi­nan­cially on edge,” so this reg­u­la­tion could place them in an even more pre­car­i­ous po­si­tion.

“If you take away tools for them to use re­sources to im­ple­ment what is now be­com­ing a na­tional pri­or­ity—on the dig­i­tal high­way— then you could have a whole sub­group of hos­pi­tals that are left be­hind in their adop­tion,” Slabach says. At the same time, the def­i­ni­tion of “EHR-el­i­gi­ble ex­pense” still lacks clar­ity for crit- ical-ac­cess hos­pi­tals, which will re­ceive Medi­care in­cen­tives based on their costs for pur­chas­ing EHR tech­nol­ogy.

“CAHs have been wait­ing for a detailed def­i­ni­tion of what qual­i­fies as an el­i­gi­ble ex­pense in or­der to make strate­gic EHR im­ple­men­ta­tion de­ci­sions,” Wen­zlow writes in his blog. “While the CMS and ONC rules pro­vide some clar­i­fi­ca­tion, many am­bi­gu­i­ties re­main,” he writes, re­fer­ring to the Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy.

Even so, un­cer­tainty about the rules should not hin­der ru­ral health­care providers from ad­vanc­ing their own health IT ini­tia­tives, says Terry Hill, ex­ec­u­tive di­rec­tor of the Ru­ral Health Re­source Cen­ter in Du­luth, Minn.

“To me, th­ese are two wrong things to do: Rush head­first and go out and do it and act too quickly without think­ing,” or “to just sit there and not work on th­ese is­sues,” Hill says of how ru­ral providers should not ap­proach health IT im­ple­men­ta­tion. In­stead, they should fo­cus on things that they want to ac­com­plish.

“Those things don’t re­quire the ONC to make their fi­nal de­ci­sion,” Hill says, adding that what he hears a lot is that many ru­ral hos­pi­tals have some things in place but are not mov­ing for­ward to ad­vance their IT pro­grams be­cause they are over­whelmed with the amount of re­quire­ments and changes. “They don’t need more in­for­ma­tion,” Hill says, “They need to know the one or two things to move for­ward with this to help them work out some road maps and readi­ness as­sess­ments, and where they are in terms of their mean­ing­ful use.”

One se­ri­ous prob­lem that could be im­ped­ing progress is the lack of qual­i­fied pro­fes­sion­als who un­der­stand not just in­for­ma­tion tech­nol- ogy, but health in­for­ma­tion tech­nol­ogy—and who are avail­able to work in ru­ral ar­eas.

“IT peo­ple in gen­eral will be the hard­est to find of all pro­fes­sions in the coun­try,” Hill says. “Then you look at the folks do­ing HIT—they’re in dra­mat­i­cally short sup­ply,” he adds. “We’re go­ing to have a very com­pelling short­age.”

Ad­dress­ing ru­ral health IT work­force chal­lenges was the fo­cus of a sum­mit held in Wash­ing­ton last Septem­ber in con­junc­tion with Na­tional Health IT Week. The sum­mit was co­or­di­nated by the Ru­ral Health Re­source Cen­ter for the Na­tional Ru­ral HIT Coali­tion, which is a net­work of ru­ral and health IT leaders from re­gional, state, na­tional and fed­eral or­ga­ni­za­tions who work to­gether to ad­vance health IT.

Since then, par­tic­i­pants have de­vel­oped rec­om­men­da­tions for health­care providers that cen­ter on data de­vel­op­ment, pol­icy and work­force re­sources. The last cat­e­gory sug­gests that providers ex­am­ine and doc­u­ment what health IT ed­u­ca­tion pro­grams now ex­ist; iden­tify cur­rent work­force re­train­ing op­por­tu­ni­ties; pro­mote in­ter­dis­ci­pli­nary ed­u­ca­tion; cre­ate cer­tifi­cates within com­mu­nity colleges and ad­vanced de­gree pro­grams that can meet ru­ral needs; and en­sure at­ten­tion to mul­ti­cul­tural, mul­ti­lin­gual needs in EHRs.

Fo­cus­ing on work­force is­sues has helped ru­ral Thayer County Health Ser­vices in He­bron, Neb., adopt health IT suc­cess­fully in the past few years. Thayer in­cludes a 19bed crit­i­cal-ac­cess hospi­tal and a clinic in He­bron, and five satel­lite clin­ics through­out the county, lo­cated in south­east­ern Ne­braska.

Ac­cord­ing to CEO Joyce Beck, ru­ral hos­pi­tals should first es­tab­lish a cul­ture that is ready for change be­fore they can have an ef­fec­tive health IT sys­tem. Beck says that a $1.6 mil­lion fed­eral grant in Septem­ber 2007 “cat­a­pulted us to where we are to­day,” which in­cludes the use of EHRs, cur­rent work on the sec­ond gen­er­a­tion of soft­ware at the clin­ics, and a staff that re­ceives on­go­ing train­ing and cer­ti­fi­ca­tion. And there’s an­other es­sen­tial el­e­ment that has helped Thayer be­come a high per­former in health IT: a physi­cian leader who em­braces the con­cept.

“Most of the physi­cians I know have kind of taken a wait-and-see ap­proach, where they’re wait­ing for some­one to tell them or show them the way. I would do the op­po­site of that,” says Ti­mothy Sul­li­van, a fam­ily prac­tice physi­cian at Thayer who also served on the grant com­mit­tee.

“The key to that is: You have to work at it, study it, look at pro­grams, go and talk to peo­ple who have been through it be­fore,” Sul­li­van says. “Quite frankly, it’s amaz­ing. The stuff will make your life bet­ter and your pa­tients’ life bet­ter.”

Ti­mothy Sul­li­van, a fam­ily prac­ti­tioner with Thayer County Health Ser­vices in Ne­braska, is an ad­vo­cate of IT.

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