The miss­ing piece in HIES

Lack of in­cen­tives leaves many fa­cil­i­ties un­plugged

Modern Healthcare - - FRONT PAGE - Joseph Conn

As the adop­tion of elec­tronic healthrecord sys­tems among hos­pi­tals and of­fice-based physi­cians sky­rock­ets, elec­tronic health in­for­ma­tion ex­change is ready to take off too, fu­eled by a grow­ing con­sen­sus on data trans­mis­sion stan­dards and pro­to­cols and mar­ket de­mands, ac­cord­ing to in­dus­try ex­perts.

Even so, a size­able seg­ment of the health­care in­dus­try is likely to re­main short­changed on full-fea­tured EHRS and full-bod­ied health in­for­ma­tion ex­change, at least in the short run, in large part thanks to Congress.

The Amer­i­can Re­cov­ery and Rein­vest­ment Act, which Congress passed in 2009, cre­ated the Medi­care and Med­i­caid EHR in­cen­tive pay­ment pro­grams that will spend an es­ti­mated $27 bil­lion. That money is limited to acute-care hos­pi­tals, of­fice-based physi­cians and a se­lect group of other health­care pro­fes­sion­als. For them, EHR adop­tion rates are soar­ing, boosted by $3.1 bil­lion in pay­ments so far. Roughly 70% of hos­pi­tals and bet­ter than 1 in 4 of­fice-based physi­cians have reg­is­tered with the pro­grams.

Congress, how­ever, ex­cluded from the EHR in­cen­tive pro­grams thou­sands of long-term care, home health and be­hav­ioral health or­ga­ni­za­tions where, ac­cord­ing to the Na­tional Gov­er­nors As­so­ci­a­tion, more than 10 mil­lion Amer­i­cans re­ceive care, but where IT use has been dubbed “frag­mented.”

Congress also blessed the Of­fice of the Na­tional Co­or­di­na­tor for Health In­for­ma­tion Tech­nol­ogy with funds “to sup­port re­gional or sub-na­tional ef­forts to­ward health in­for­ma­tion ex­change.” The ONC has al­lo­cated more than $548 mil­lion to states, ter­ri­to­ries and the Dis­trict of Columbia to set up health in­for­ma­tion ex­changes. But only $6.8 mil­lion in ad­di­tional chal­lenge grants was tar­geted to im­prove longterm-care and posta­cute tran­si­tions in four states. In Fe­bru­ary, the ONC and the CMS re­leased pro­posed rules for the EHR pro­gram that in­cluded new re­quire­ments on health in­for­ma­tion ex­change.

“We can’t wait five years for in­ter­op­er­abil­ity and ex­change,” says ONC chief Dr. Farzad Mostashari. “We need to move ahead with ‘good enough’ stan­dards and we have good enough stan­dards now for trans­port. I ex­pect to see a hockey stick curve for ex­change, just as we’ve seen for adop­tion.”

Dr. Les­lie Len­ert, pro­fes­sor of medicine and bio­med­i­cal in­for­mat­ics at the Univer­sity of Utah School of Medicine in Salt Lake City, says the feds took a wrong turn on ex­change.

Len­ert au­thored a con­tro­ver­sial ar­ti­cle, “Shifts in the ar­chi­tec­ture for the na­tion­wide health in­for­ma­tion net­work,” pub­lished in the March is­sue of the Jour­nal of the Amer­i­can Med­i­cal In­for­mat­ics As­so­ci­a­tion. In it he pos­tu­lates that in 2009, fed­eral IT pol­icy shifted away from an em­pha­sis on not-for-profit, re­gional health in­for­ma­tion or­ga­ni­za­tions, or RHIOS, as the chief fa­cil­i­ta­tors of elec­tronic record-shar­ing. Now, Len­ert says, RHIOS are just one of many ex­change al­ter­na­tives that in­clude state ex­changes, pri­vate net­works and one-to-one com­mu­ni­ca­tions be­tween providers us­ing the Onc-de­vel­oped Di­rect pro­to­col.

By pro­mot­ing many al­ter­na­tives, Len­ert says, the feds un­der­mine RHIOS, whose mis­sion in­cludes serv­ing as public util­i­ties, ex­tend­ing con­nec­tiv­ity across com­mu­ni­ties, even to or­ga­ni­za­tions that can’t af­ford to pay for it.

“Pre­ma­ture re­tir­ing of the RHIO model through shifts in fund­ing and in­creased com­pe­ti­tion from pri­vate data ex­change net­works could re­sult in se­ri­ous long-term loss of the com­mu­nity-level func­tions,” Len­ert writes.

His con­clu­sions were chal­lenged in cri­tiques posted by sev­eral IT ex­perts in a lively vol­ley of more than 110 com­ments on Google Plus, in­clud­ing re­sponses from Arien Malec, a vice pres­i­dent at Re­layhealth, a health in­for­ma­tion ex­change soft­ware de­vel­oper and a Mckes­son Corp. health IT sub­sidiary. Malec pre­vi­ously headed sev­eral in­ter­op­er­abil­ity projects at the ONC.

Malec likened many RHIOS to “rent-seek­ing” mo­nop­o­lies. “If you are start­ing a RHIO and your sus­tain­abil­ity model is not based on adding value to your cus­tomers, but on ex­tract­ing mo­nop­oly rents on the ser­vices your cus­tomers are ask­ing for and us­ing those mo­nop­oly rents to pro­vide ser­vices that your cus­tomers aren’t ask­ing for but you think they should want, you will fail,” Malec says in one of sev­eral posts.

So, where does that leave long-term-care providers in the fed­eral ex­change pol­icy scheme?

Clau­dia Wil­liams, di­rec­tor of the ONC’S State Health In­for­ma­tion Ex­change Pro­gram, in a co-au­thored ar­ti­cle on ex­change pol­icy pub­lished this month in Health Af­fairs, writes that the ONC “seeks to lever­age ex­change ac­tiv­ity while ad­dress­ing the gaps and un­in­tended con­se­quences of a mar­ket-based ap­proach.” In an in­ter­view, Wil­liams says the ONC will be lean­ing not on man­dates, such as re­quir­ing providers to join a RHIO as part of mean­ing­ful use, a Len­ert rec­om­men­da­tion, but on pay­ment re­forms, to achieve wide­spread ex­change.

“In the con­text of pay­ment re­form, you can’t get to the goals with­out HIE,” Wil­liams says.

Ac­cord­ing to the Amer­i­can Hospi­tal As­so­ci­a­tion, there are 15,000 skilled-nurs­ing fa­cil­i­ties in the U.S., 10,400 home health agen­cies, 1,200 in­pa­tient re­hab fa­cil­i­ties and 430 long-term acute-care hos­pi­tals. More than 10 mil­lion el­derly, dis­abled and de­vel­op­men­tally dis­abled Amer­i­cans use long-term-care ser­vices, con­sti­tut­ing 32% of state Med­i­caid bud­gets, ac­cord­ing to the Na­tional Gov­er­nors As­so­ci­a­tion.

And yet, “clin­i­cal data with long-term-care

providers is of­ten frag­mented due to an­ti­quated record sys­tems that col­lect only a por­tion of a pa­tient’s health in­for­ma­tion,” ac­cord­ing to an NGA brief on IT in­te­gra­tion in long-term care.

The head­line of an­other ar­ti­cle in the March is­sue of Health Af­fairs, “Hos­pi­tals in­el­i­gi­ble for fed­eral mean­ing­ful-use in­cen­tives have dis­mally low rates of adop­tion of elec­tronic health records,” tells their IT story.

Ac­cord­ing to its au­thors, whose work was based on a 2009 AHA sur­vey, while 12% of Arra-el­i­gi­ble acute-care hos­pi­tals had at least a “ba­sic EHR,” among or­ga­ni­za­tions in­el­i­gi­ble for ARRA, 6% of long-term acute-care hos­pi­tals, 4% of re­ha­bil­i­ta­tion hos­pi­tals and 2% of psy­chi­atric hos­pi­tals had ba­sic EHR sys­tems. No more than 2% had full-fea­tured, “com­pre­hen­sive EHRS” and “very few” had the IT ca­pac­ity to meet fed­eral mean­ing­ful-use stan­dards un­der the ARRA.

Congress ex­cluded long-term-care providers from the ARRA “pri­mar­ily be­cause of fund­ing con­straints and un­cer­tainty about their readi­ness to adopt EHR sys­tems,” the au­thors say. But ig­nor­ing these providers’ IT needs will have neg­a­tive “spillover ef­fects,” they say. “If large seg­ments of the health­care sys­tem re­main pa­per-based, then in­vest­ments to sup­port EHR adop­tion and use by el­i­gi­ble hos­pi­tals and physi­cians might not pro­duce the ex­pected qual­ity and ef­fi­ciency gains.”

There is no sim­i­lar, cur­rent, na­tion­wide sur­vey of EHR adop­tion in nurs­ing homes, ac­cord­ing to Michelle Dougherty, di­rec­tor of re­search and de­vel­op­ment at the AHIMA Foun­da­tion, which acts as the con­vener of the an­nual LongTerm and Post-acute Care Health IT Sum­mit.

The com­mon per­cep­tion is that long-term care is to­tally bereft of IT, “and that’s not the case,” Dougherty says. Most nurs­ing homes and home-care agen­cies have some elec­tronic record­keep­ing ca­pa­bil­ity to com­pile CMS re­ports. Mean­while, Onc-funded chal­lenge grant pro­grams are mak­ing some progress in con­nect­ing hos­pi­tals with post-acute providers, she says.

In its re­cent pro­posed rule, the ONC asked for public com­ments on whether it would be “pru­dent” for it to ap­prove test­ing and cer­ti­fi­ca­tion pro­grams—as it does with such pro­grams for EHRS for Arra-el­i­gi­ble providers—for IT sys­tems for providers in­el­i­gi­ble for ARRA in longterm care, post-acute and men­tal and be­hav­ioral health, or leave such test­ing to the pri­vate sec­tor.

The Colorado Re­gional Health In­for­ma­tion Or­ga­ni­za­tion, one of the four ONC chal­lenge grant re­cip­i­ents, seeks to con­nect its 18 mem­ber hos­pi­tals statewide with 160 long-term-care providers in four tar­get com­mu­ni­ties, says Phyl­lis Albrit­ton, CORHIO ex­ec­u­tive di­rec­tor.

“We went live a cou­ple of weeks ago,” says Scott Buck, a Pue­blo, Colo.-based reg­is­tered nurse and branch di­rec­tor of home health provider Gen­tiva Health Ser­vices, which serves 150 pa­tients a day in Pue­blo. Gen­tiva was CORHIO’S first long-term-care con­nec­tion. “We’ve al­ways been able to get a his­tory and phys­i­cal,” he says, but now, “there is so much more—a lab re­port, a ra­di­ol­ogy re­port, whether they’ve had a swal­low study, a sup­ple­men­tal re­port that re­ally rounds out what hap­pened to a pa­tient in a hospi­tal.”

Ac­cord­ing to Buck, Congress missed an op­por­tu­nity by not pro­vid­ing IT in­cen­tives to skilled-nurs­ing providers. “I think a lot of what hap­pened was the leg­is­la­tors didn’t un­der­stand health­care,” Buck says. “When you think health­care, you think hospi­tal. You think doc­tor—even though home care costs less. One day in the hospi­tal can cost you more than 60 days on home health. I think this is the track that this has to go. We have to get strongly into the care­tran­si­tion process.”

Read the full ver­sion of this story and view more data at mod­ern­health­

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