Too steep to climb

Pro­posed mean­ing­ful-use regs ask too much, too soon of providers

Modern Healthcare - - Opinions Commentary - Tim Stet­theimer

As a chief in­for­ma­tion of­fi­cer who has long be­lieved in the value and crit­i­cal need for in­te­grat­ing com­put­ers into the de­liv­ery of health­care, I couldn’t be more ex­cited about the de­vel­op­ments of the past year.

The fed­eral gov­ern­ment sees the dig­i­ti­za­tion of health­care de­liv­ery as an es­sen­tial foun­da­tion for bring­ing about re­form in the na­tion’s health­care sys­tem. As part of ef­forts to re­vi­tal­ize the econ­omy, fed­eral leg­is­la­tors have backed ad­di­tional fund­ing to help providers im­ple­ment elec­tronic health records in a mean­ing­ful way.

Much of the past year has fo­cused on de­ter­min­ing ex­actly what “mean­ing­ful use” means when it comes to elec­tronic health records. Dozens of com­mit­tee mem­bers have been help­ing to de­fine the specifics of what con­sti­tutes the mean­ing­ful use of th­ese records. The def­i­ni­tion, em­bod­ied in reg­u­la­tions re­leased Dec. 30, 2009, sets a high bar for providers to clear.

How many health­care providers will be left be­hind with this mean­ing­ful-use def­i­ni­tion? Ap­par­ently, if the pro­posed def­i­ni­tion holds, the an­swer will prob­a­bly be “the ma­jor­ity.”

The fed­eral gov­ern­ment has set forth a laud­able vi­sion of “a trans­for­ma­tion of our health sys­tem to im­prove health­care qual­ity, ef­fi­ciency, eq­uity and safety through the use of health in­for­ma­tion tech­nol­ogy.” This vi­sion is a wor­thy one, and the cur­rent ad­min­is­tra­tion points to the po­ten­tial sav­ings just wait­ing to be gath­ered from the wide­spread de­ploy­ment of health­care IT.

There’s just one prob­lem. Suc­cess­fully im­ple­ment­ing tech­nol­ogy in­volves more than just in­stalling tech­nol­ogy. The cur­rent dis­cus­sion on mean­ing­ful use of health­care IT hints at this, but it still pro­poses some­what of a “black box” re­al­ity. It’s the start of a dig­i­tal trans­for­ma­tion, but cer­tainly it doesn’t rep­re­sent the en­tire process that needs to oc­cur.

The mean­ing­ful-use def­i­ni­tions linked to in­cen­tives and penal­ties for providers in­clude nu­mer­ous de­tails—if you would like some light read­ing, pe­ruse the 556-page fil­ing in the Fed­eral Reg­is­ter— but some­how it still feels like sausage­mak­ing.

Cer­tainly “health out­come pri­or­i­ties” and “care goals” are listed along with as­so­ci­ated ob­jec­tives and mea­sures. How­ever, the chal­lenge for IT pro­fes­sion­als specif­i­cally—and the na­tion’s health­care providers in gen­eral— lies in get­ting from A to Z in bring­ing tech­nol­ogy to bear on trans­form­ing the sys­tem.

I know of no one in health­care who de­nies the po­ten­tial value of th­ese com­po­nents in the def­i­ni­tion of “mean­ing­ful use.” What is more dif­fi­cult to agree on is how to re­al­ize them— how to truly ar­rive at the ul­ti­mate des­ti­na­tion.

Cer­tainly, only a mi­nor­ity of hos­pi­tals, physi­cians and other care providers will be able to meet mean­ing­ful-use tar­gets on the timeta­bles for in­cen­tives pro­posed by the CMS. Even the CMS ap­par­ently rec­og­nizes this, be­cause they have low­ered their pro­jec­tions for the even­tual to­tal of stim­u­lus pay­ments—the orig­i­nal es­ti­mate of $34 bil­lion may dwin­dle to as lit­tle as $14 bil­lion, ac­cord­ing to the CMS.

Set­ting a high bar for what con­sti­tutes mean­ing­ful use has the ef­fect of lim­it­ing stim­u­lus dol­lars that will be dis­trib­uted and could ac­tu­ally drop fu­ture costs for fed­eral pro­grams by broad­en­ing penal­ties to the ma­jor­ity of providers who are un­able to im­ple­ment EHRs by 2015. The net re­sult could in­clude more hos­pi­tals los­ing money and the po­ten­tial for a de­cline in the num­ber of physi­cians, even as fewer from fu­ture gen­er­a­tions are en­ter­ing the med­i­cal pro­fes­sion.

So how do we put this ef­fort back on track to meet the stated goals? If we move pol­i­tics and hy­per­bole out of the way, it ac­tu­ally is pretty straight­for­ward: ■ Make all providers el­i­gi­ble for pay­ments, in­clud­ing hospi­tal-based physi­cians. ■ En­sure full align­ment of Medi­care and Med­i­caid cri­te­ria for mean­ing­ful use. ■ Al­low the “90-day qual­i­fi­ca­tion pe­riod” for mean­ing­ful use in the first year of a provider’s ef­forts, re­gard­less of the cal­en­dar year in­volved. ■ Re­duce or elim­i­nate the Med­i­caid thresh­old for qual­i­fi­ca­tion for in­cen­tives. ■ Re­visit the stag­ing of qual­ity goals and have fewer goals with lower thresh­olds up­front, and then, as providers ben­e­fit from stim­u­lus pay­ments and be­come versed in the use of health­care IT, boost those thresh­olds over time. ■ Move re­quire­ments to im­ple­ment com­put­er­ized physi­cian or­der en­try, or CPOE, to Stage 3, which would be­gin in fis­cal 2015. CPOE is a tech­nol­ogy that re­quires too many other IT “feeder sys­tems” to be ef­fec­tively de­ployed at the front end, as it is cur­rently sched­uled to be.

The bot­tom line is that we need to get money into the hands of providers faster. This is the in­vest­ment side of the equa­tion. Without the money to ac­com­plish th­ese goals, many hos­pi­tals and physi­cians just can’t fund the ef­fort.

So what op­tions would the CMS have if it pays all the planned in­cen­tives out be­fore the end-state is achieved? They can al­ways slap oner­ous penal­ties on later af­ter health­care providers have at least tried to reach the mark. It’s a bet­ter ap­proach than set­ting up a sys­tem that makes it likely that very few providers will ever suc­ceed in max­i­miz­ing stim­u­lus re­im­burse­ment.

The ba­sic ques­tion is: What are we re­ally try­ing to ac­com­plish? If the an­swer is that we are try­ing to ef­fect “a trans­for­ma­tion of our health sys­tem,” then we need to cre­ate a path to that des­ti­na­tion, not a se­ries of ob­struc­tions. <<

Tim Stet­theimer is chair­man of the board

of the Col­lege of Health­care In­for­ma­tion Man­age­ment Ex­ec­u­tives and is a re­gional chief in­for­ma­tion of­fi­cer for As­cen­sion Health,

St. Louis.

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