Ex­ecs' IT pri­or­i­ties in flux with shift­ing land­scape

An­nual sur­vey high­lights ex­ecs’ pri­or­i­ties as they try to steer through the shift­ing reg­u­la­tory land­scape for health­care IT

Modern Healthcare - - FRONT PAGE - Joseph Conn

If you don’t like how things are go­ing with health in­for­ma­tion tech­nol­ogy, stick around. The rules will change. Mean­ing­ful use is once again the main con­cern of hospi­tal and med­i­cal group prac­tice lead­ers in the in­for­ma­tion tech­nol­ogy sphere as expressed by those who par­tic­i­pated in the 22nd an­nual Mod­ern Health­care/mod­ern Physi­cian Sur­vey of Ex­ec­u­tive Opin­ions on Key In­for­ma­tion Tech­nol­ogy Is­sues.

But the reg­u­la­tory back­drops for mean­ing­ful use and an­other ma­jor is­sue mea­sured on this year’s sur­vey—achiev­ing com­pli­ance with the ICD-10 code sets—re­main in flux.

The reg­u­la­tory en­vi­ron­ment for mean­ing­ful use has changed con­sid­er­ably since Nov. 16, 2011, the day our sur­vey was launched, and for ICD-10, sig­nif­i­cantly, since just last week. Still an­other ma­jor change is ex­pected with the CMS’ pro­posed rule for Stage 2 mean­ing­ful-use cri­te­ria.

Amid the tu­mult, health­care ex­ec­u­tives have tried to steer a straight course. In this year’s sur­vey, as in the past two years, they in­di­cated in mul­ti­ple ways that their great­est health IT chal­lenge is in their or­ga­ni­za­tions’ quest to be­come mean­ing­ful users of elec­tronic health-record sys­tems. For ex­am­ple, this year we asked lead­ers to choose their top three “hot but­ton” IT pri­or­i­ties, giv­ing them a list of 23 cur­rently rel­e­vant IT projects from which to choose.

Head­ing the top five choices was meet­ing the mean­ing­ful-use cri­te­ria of the Medi­care (and even­tu­ally Med­i­caid) EHR in­cen­tive pay­ment pro­grams. Mean­ing­ful use was cho­sen by half of sur­vey par­tic­i­pants (See chart at left). ICD10 ran a close sec­ond, se­lected by 49% of re­spon­dents; fol­lowed by im­ple­ment­ing EHR sys­tems, a com­po­nent part of meet­ing mean­ing­ful-use cri­te­ria, se­lected by 37% of re­spon­dents; adopt­ing am­bu­la­tory clin­i­cal IT sys­tems, 16%; and de­vel­op­ing an­a­lyt­ics ca­pa­bil­i­ties in their fi­nan­cial and clin­i­cal sys­tems in prepa­ra­tion for the an­tic­i­pated cre­ation of ac­count­able care or­ga­ni­za­tions, 16%.

By be­com­ing a mean­ing­ful user, a hospi­tal, physi­cian or other “el­i­gi­ble pro­fes­sional” qual­i­fies to re­ceive siz­able fed­eral in­cen­tive pay­ments in the near term as well as avoid stiff fi­nan­cial penal­ties down the road.

The con­cept of mean­ing­ful use and the EHR in­cen­tive pay­ment pro­grams un­der Medi­care and Med­i­caid were cre­ated by the Amer­i­can Re­cov­ery and Rein­vest­ment Act of 2009. To

qual­ify for Medi­care in­cen­tive pay­ments, hos­pi­tals had to achieve 90 con­sec­u­tive days of mean­ing­ful use by Sept. 30, 2011; physi­cians and other el­i­gi­ble pro­fes­sion­als by Dec. 31, 2011. Through De­cem­ber, 1,658 hos­pi­tals and more than 29,300 el­i­gi­ble pro­fes­sion­als have shared in $2.5 bil­lion in EHR in­cen­tive pay­ments from the two pro­grams, ac­cord­ing to the lat­est CMS data.

Al­most half (49%) of re­spon­dents to this year’s sur­vey in­di­cated their or­ga­ni­za­tions ei­ther had met Stage 1 mean­ing­ful-use cri­te­ria, at­tested to that fact and qual­i­fied for ARRA in­cen­tive pay­ments in 2011, or they ex­pected their or­ga­ni­za­tions to do so (See chart at right).

Not sur­pris­ingly, given the high stakes, lead­ers in our sur­veys in 2010 and 2011 also listed meet­ing mean­ing­ful-use re­quire­ments as their top IT pri­or­ity. An­other press­ing con­cern for health­care ex­ec­u­tives this year, ac­cord­ing to the sur­vey, was the fed­er­ally man­dated con­ver­sion from the ICD-9 di­ag­nos­tic and pro­ce­dural codes now in cur­rent use to the sub­stan­tially more com­plex ICD-10 fam­ily of codes.

When lead­ers were asked to se­lect their four top IT sys­tem pri­or­i­ties dur­ing the next 24 months, giv­ing them 21 project choices, achiev­ing ICD-10 readi­ness headed the list by a wide mar­gin, se­lected by 72% of re­spon­dents. That was no sur­prise. The pro­posed final com­pli­ance date for the oft-de­layed con­ver­sion to ICD-10 was sup­posed to be Oct. 1, 2013.

Dr. Justin Gra­ham was in the mi­nor­ity (26%) of health­care lead­ers in the sur­vey who re­sponded that nei­ther ICD-10 readi­ness nor meet­ing mean­ing­ful-use cri­te­ria were hot but­ton is­sues. Gra­ham is the chief med­i­cal in­for­ma­tion of­fi­cer for two-hospi­tal North­bay Health­care in Fair­field, Calif.

Gra­ham says his or­ga­ni­za­tion achieved mean­ing­ful use in 2011, at least in part, just as he pre­dicted in the sur­vey, and that’s why mean­ing­ful use wasn’t a high pri­or­ity.

“We had Stage 1 nailed on the in­pa­tient side,” Gra­ham says. Pro­vid­ing an out­pa­tient EHR for 30 to 40 physi­cians in four af­fil­i­ated pri­mary-care prac­tices, how­ever, is prov­ing to be “more of a chal­lenge for us,” he says.

“We have not rolled out e-pre­scrib­ing,” he says, which is a key mean­ing­ful-use re­quire­ment in the out­pa­tient set­ting. “So one of the chal- lenges of hav­ing an in­pa­tient EHR is we have a phar­macy cat­a­log that re­flects in­pa­tient pre­scrib­ing pat­terns, so there’s a lot of things that need to be cleaned up,” he says.

Both ICD-10 and mean­ing­ful use were among Gra­ham’s top four pri­or­i­ties in the next 24-month time frame.

But just last week, CMS act­ing Ad­min­is­tra­tor Marilyn Taven­ner put the ICD-10 com­pli­ance time­line in limbo, telling re­porters that the agency will “re-ex­am­ine the time frame” for the ICD-10 roll­out through the rule­mak­ing process.

HHS Sec­re­tary Kath­leen Se­be­lius backed up Taven­ner, say­ing in a pre­pared state­ment that HHS would use rule­mak­ing to de­lay ICD-10. A day later, Se­be­lius ap­peared to back­track a bit, is­su­ing a sec­ond state­ment not men­tion­ing rule­mak­ing, say­ing that HHS would merely “ini­ti­ate a process to post­pone the date.”

The reg­u­la­tory de­lay comes af­ter the Amer­i­can Med­i­cal As­so­ci­a­tion’s House of Del­e­gates in Novem­ber called for the or­ga­ni­za­tion to work to block the 2013 im­ple­men­ta­tion of ICD-10 and af­ter AMA Ex­ec­u­tive Vice Pres­i­dent and CEO Dr. James Madara wrote let­ters to House Speaker John Boehner and Se­be­lius call­ing for a halt to ICD-10.

ICD-10 readi­ness was a hot but­ton is­sue and a 24-month pri­or­ity for Vicki Parks on this year’s sur­vey. Parks is chief fi­nan­cial of­fi­cer for 131-bed Mur­ray (Ky.)-cal­loway County Hospi­tal. Still, the ICD-10 reg­u­la­tory re­set “will be a hugely wel­come thing,” Parks says. The hospi­tal has not yet fully re­cov­ered from the hit to its cash flow caused by glitches in the re­cent, fed­er­ally man­dated con­ver­sion to the ASC X12 Ver­sion 5010 elec­tronic claims and other fi­nan­cial trans­ac­tion stan­dards, she says. The com­pli­ance date to switch from the old Ver­sion 4010 stan­dards to 5010 was Jan. 1.

“The con­ver­sion we went through to 5010 was pretty bad,” Parks says. There was a glitch in pro­cess­ing Medi­care claims with phar­macy codes, she says. “They just weren’t go­ing on through. So you’d have a $50,000 claim re­jected for a $5 phar­macy bill.” The hospi­tal switched to 5010 on Dec. 5, 2011, and in the two months since, “we went down about $2 mil­lion,” she says.

In terms of com­plex­ity and dif­fi­culty, the up­grade from 4010 to 5010, deemed a needed pre­cur­sor for the switch to ICD-10, “is noth­ing com­pared to ICD-10,” Parks says. She says a con­sul­tant rec­om­mended hos­pi­tals have “a min­i­mum of six months’ cash on hand” for ICD-10. “We don’t have six months of cash on hand. I don’t know what that would do to the smaller fa­cil­i­ties. It would be dev­as­tat­ing.”

At the be­gin­ning of the sur­vey pe­riod, ex­ec­u­tives ex­pected that they would have to meet the more strin­gent Stage 2 mean­ing­ful-use cri­te­ria in 2013. Some 69% of sur­vey re­spon­dents es­ti­mated it was ei­ther highly likely (43%) or some­what likely (26%) their or­ga­ni­za­tions would be able to be Stage 2 mean­ing­ful users by 2013. An­other 18% were un­sure, with 6% feel­ing it was some­what un­likely, and an­other 6% highly un­likely that they would meet Stage 2 in time.

But in late Novem­ber, roughly two weeks af­ter our sur­vey was re­leased, the CMS an­nounced it would push back the Stage 2 com­pli­ance dead­line into 2014 for or­ga­ni­za­tions that achieved mean­ing­ful-use re­quire­ments in 2011. CMS of­fi­cials rea­soned that the time frame for de­vel­op­ing Stage 2 mean­ing­ful-use cri­te­ria was too tight to af­ford EHR ven­dors and providers enough time to up­date their sys­tems and pre­pare for the more strin­gent cri­te­ria.

In Jan­uary, the CMS sent a draft of the pro­posed Stage 2 rules to the White House for re­view by the Of­fice of Man­age­ment and Bud­get, typ­i­cally a last step be­fore rules are re­leased.

In this year’s sur­vey, health­care lead­ers also were asked about meet­ing Stage 3 cri­te­ria, which were ex­pected to be in place by 2015. Lead­ers were al­most as op­ti­mistic about Stage 3 as they were about Stage 2, with 62% say­ing it was ei­ther highly likely (38%) or some­what likely (24%), they would meet Stage 3 goals on time. An­other 28% said they were un­sure about Stage 3, while 3% said it was some­what un­likely and 6% highly un­likely.

The 24-month out­look

Even with con­fi­dence lev­els this high, or per­haps be­cause of them, among the 24-month IT ini­tia­tives on the sur­vey, meet­ing mean­ing­ful-use cri­te­ria and qual­i­fy­ing for fed­eral re­im­burse­ments ranked sec­ond among health­care lead­ers this year, cho­sen by nearly 58% of sur­vey re­spon­dents.

Five other longer-term IT ini­tia­tives clus­tered well be­low ICD-10 and mean­ing­ful use were se­lected by 25% to 22% of sur­vey re­spon­dents: Im­prove IT ca­pa­bil­i­ties for pa­tient care/clin­i­cal qual­ity and pa­tient safety, 25%; im­prove clin­i­cal decision sup­port, 24%; im­prove pro­duc­tiv­ity and re­duce costs, 23%; par­tic­i­pate in state and re­gional health in­for­ma­tion ex­changes, 22%; and pro­vide pa­tient ac­cess to sched­ul­ing, test re­sults and com­mu­ni­ca­tion with clin­i­cians via a Web-based pa­tient por­tal or se­cure e-mail, 22%.

To get a feel for what are the most com­mon IT projects in the works, the sur­vey in­cluded a se­ries of ques­tions about the sta­tus of 14 soft­ware sys­tems or IT pro­grams, ex­clud­ing mean­ing­ful-use prepa­ra­tions but in­clud­ing ICD-10 readi­ness. ICD-10 topped the list of im­ple­men­ta­tions in progress, se­lected by 42% of sur­vey re­spon­dents. Other pop­u­lar projects in cur­rent im­ple­men­ta­tion and their per­cent­ages of re­spon­dents are: work­flow au­to­ma­tion, 40%; com­put­er­ized physi­cian-or­der en­try, 37%; clin­i­cal decision sup­port at the point of care, 32%; and us­ing the clin­i­cal care doc­u­ment/clin­i­cal care record for­mats for the ex­change of care sum­maries and other clin­i­cal mes­sages, 31% (See chart be­low).

ICD-10 also topped the list of im­ple­men­ta­tions start­ing in within 12 months, at 36%, fol­lowed by launch­ing pa­tient por­tals, 25%; par­tic­i­pat­ing in a re­gional or statewide health in­for­ma­tion ex­change, 21%; set­ting up a clin­i­cal data repos­i­tory for care data anal­y­sis, 21%; and of­fer­ing pa­tients a per­sonal health record sys­tem, 20%.

The project most fre­quently listed as be­ing on the ex­ec­u­tives’ radar but not yet started, was a PHR, se­lected by 30% of re­spon­dents. Two pro­grams—adding a cost-track­ing sys­tem and set­ting up a pa­tient por­tal—fol­lowed in pop­u­lar­ity among sur­vey re­spon­dents, tied at 24%. Af­ter them came join­ing a RHIO/HIE, 23%; and work­flow au­to­ma­tion, 17%.

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