(Back Row) Ralph P. Fargnoli, Jr., Paul Hudson (Front) Minor Anderson, Pamela McNutt, Fawn Lopez, Lac Tran, Jeana O'Brien
The Centers for Medicare & Medicaid Services (CMS)
released final rules in July on the criteria providers
must meet to become meaningful users of an
electronic medical-record system and qualify for
incentive payments under the economic stimulus
law. With the first deadline to earn payments
looming in July 2011, providers don’t have much
time to implement the first stage of the three-stage
program. That’s why Modern Healthcare and
Beacon Partners hosted a roundtable discussion on
the topic on August 3, 2010 at Modern Healthcare’s
Chicago headquarters. Fawn Lopez, vice president
and publisher of Modern Healthcare, was the
moderator.
Q: To begin this discussion, will each of you tell us where your organization is in the process of meeting Stage 1 meaningful use targets by 2011?
Paul Hudson
COO and CIO
Sutter Physician Services
Sacramento, Calif.
Hudson: Overall, the physicians within Sutter Foundation should be in a good position to achieve the meaningful use criteria in 2011 since the majority of the providers use a robust electronic health-record system. As far as the Sutter hospitals, I am not as familiar with their current systems and readiness.
O'Brien: Provided our existing vendor systems are certified at Scott & White Healthcare, our employed physicians will be able to meet meaningful use targets by 2012. We have not yet deployed our ambulatory electronic medical record (EMR) in all of our clinics. We have a very aggressive schedule for this next year, which involves process change as well as the deployment of the EMR. The major hospitals should be able to get there by 2012 as well.
Jeana O’Brien
CMIO
Scott & White Healthcare
Temple, Texas
Anderson: We are shooting to be compliant in 2012 as well. The University of Southern California is really starting late to the game. It is ironic that it is the oldest medical school west of the Mississippi, but it is also the newest in the following sense: Up until a year ago, we didn't own the hospitals. Our clinical departments were in 18 totally separate 501(c)3 corporations. It is only in the last year that we have brought all of these fragments together. We have two hospitals and 600 doctors, who have a tradition of very independent practice. It is going to be a challenge.
McNutt: At Methodist Health System, we expect that our legacy hospitals will be able to achieve meaningful use by late 2011. Our owned physicians and clinics are also in very good shape to obtain meaningful use as well. Some of our other facilities, such as the hospital system that we acquired last year, will obtain meaningful use in 2012. As far as some of our newer joint-venture hospitals, those may take a little longer.
Tran: We are in good shape on the inpatient side and on the employed-physician side at Rush University Medical Center to be ready by 2011. There will be a fraction of private practices that will be ready in 2011. Because of the competitive nature of the Chicago area, some of these private physicians practice at multiple places. We have a strategy to court them to join with us. We feel very confident that the people who sign up with us will be ready by 2011.
Q: What part of the meaningful use criteria do you believe will be the hardest to achieve?
Pamela McNutt
Senior VP and CIO
Methodist Health System
Dallas
McNutt: The inpatient and emergency department requirement for computerized physician order entry (CPOE) will be the hardest. Usually, you lay a good foundation with an EMR system and then you put CPOE on top of it. But the meaningful use incentives may cause people who were not very far in the adoption curve to rush that process. CPOE requires a lot of ongoing technical support for front-line users.
O'Brien: The government tried to make CPOE adoption easier by only requiring automation of medication orders in Stage 1. The reality is this: When you are doing orders in a hospital, you usually aren't writing just a medication order. As a clinician, it doesn't make sense to do most of your orders on paper and then go over to the computer to do a medication order. That is not reality. Your systems and your training really have to be geared toward full CPOE implementation.
Tran: Training is a huge obstacle. You need dollars for training—and not just the training the vendor provides. The workflow-design process also is an obstacle as is providing the technical support for your front-line people. Competing for IT talent would be difficult, especially in a very competitive market, such as Chicago or Dallas, since all of us are recruiting for that core resource.
Hudson: Finding the people who can provide the training is another challenge. There is a whole group of people yet to be recruited for the training effort. Training clinicians will take significant engagement, given the complexity of working with electronic health records and the features required to meet the meaningful use criteria.
Q: You brought up a great point: the dollars and cents. What is the business case for obtaining Stage 1 meaningful use?
Lac Tran
Senior VP and CIO
Rush University Medical Center
Chicago
Hudson: It is about how to obtain the stimulus money, which is quite significant, and then avoiding the penalties. Fortunately, the Sutter physicians are mostly there. I think it will be a steep curve for the providers who have not started on the journey. The incentive money will motivate more providers to want to meet the criteria. The pace for deploying qualified electronic health-record systems will be faster in the coming years.
Tran: There are some private physicians—some of the older generation—who are willing to take the penalties or drop out of Medicare rather than invest in an EMR.
Q: Let's talk about the alignment with private practices. What is driving you to align with private physicians?
Minor Anderson
President and CEO
USC Care Medical Group
Los Angeles
McNutt: Since we are largely a volunteer medical staff, this is very significant for us. The main driver of why we would like to see those practices come to us for their practice management and electronic medical-record systems is to capture what is going on clinically as we move into other types of care models and payment models. The stimulus package is driving physicians to want to go out and purchase an electronic medical-record system. We are hoping they will turn to us for that, which, in turn, benefits us, too. We are just entering that phase now that we have all of our employed physicians up on our EMR. We are in the midst of investigating a care delivery model proposed by healthcare reform. I do believe we will go after the practices that would benefit from transparency of data, but that might not be exclusively who we are going to go after.
Tran: Most academic health centers typically have strong research programs with population-based research. The more patients you serve, the more data you acquire for research. It is also about growing in a highly competitive region, such as Chicago, Boston or Dallas; the growth in market share is, at best, moderate, and therefore, referrals to your specialized clinics or specialized hospitals are important.
Q: Earlier we talked about the business case for meaningful use. Now, let's talk about the business risk.
McNutt: A business risk is that you could spend too much money on healthcare IT, and that could be very detrimental to the rest of your operations, given the whole healthcare reform environment.
O'Brien: I think there is some risk for those who very aggressively bring in other physicians. The organization could end up offering a service, like EMR, to a lot of area providers, but end up without much return on investment.
Fargnoli: Organizations are spending between $50 million and $70 million, but does it get them to the point of preventative medicine and away from reactive medicine? Have we really changed anything or did we just adopt technology? Many organizations are using technology as a means to try to change culture. We saw that with the billing systems. Technology was always used as a means to get someplace, but it never changed healthcare delivery.
O'Brien: Technology is simply a tool, and tools alone cannot build a house. You must also have culture, process and people. All of the components have to be there. Going back to the house analogy, your contractor must be there using appropriate technology tools to achieve your ultimate outcome, which, in this case, is better, safer care with more preventative focus and less reactive focus.
Tran: Measurement is really important. It is imperative for an organization to do that. You have two groups: One that jumps in because of the dollars and another that is really careful and invests in EMR because it fits with the organization's overall strategy. That group will be able to sustain their investment. The first group is going to have tremendous challenges.
Q: From a technology standpoint, are you gravitating to a best-of-breed system or a single vendor?
McNutt: At Methodist, we do insist that the hospitals that we acquire—even if it is a joint venture—be on our electronic medical-record platform. We use a vendor that covers us from soup to nuts, so it is very cost effective for us to bring on these other institutions. We think that is a good model, and we are fortunate to be able to do that because it cuts down on support costs. We have staff that is already trained and templates that are already developed.
Tran: Most of us have some sort of hybrid scenario with multiple vendors. It is really the middleware that ties these systems together. Does the middleware have to be certified as well? That is what all of us really worry about. It is not clear.
McNutt: Certification is an aspect of this process that is going to trip up some organizations. What if you have a best-of-breed solution? There is this concept of bundled EMR and certified modules, but how is this going to fit together? How are you going to know that you are truly certified for everything you are doing? I can pretty much guarantee that for most of your vendors, the certified release is not the release you are sitting on today. You are going to have to do some upgrades to your systems. Hopefully, they will be minor. You may also have to go back and look at your modifications to the various systems and make sure you don't have to obtain self-certification.
Q: How will you deal with privacy and security issues?
McNutt: I think we are at a loggerhead here between the transparency of data versus the privacy. If we go too far with patient privacy by ratcheting down on what a provider can see, the physicians aren't going to use the system. If the physicians don't use the system, we are defeated. On the other hand, if the patients don't want to give us any data because they are afraid of how it is going to be used, we are also going to be defeated.
O'Brien: There also are challenges for vendors. Hiding components of an electronic medial record is one example. In the paper world, it is pretty easy to limit this access. Some patients will pay for tests themselves because they don't want the results released to their third-party payers. As part of the privacy regulations, we must be able to honor this request. From a technical and operational perspective, we must be able to do this without diminishing flow and efficiency for the thousands of other test results.
Q: How have your internal audit, compliance and legal teams been involved in the process of obtaining meaningful use?
O'Brien: We have a group of people who started getting together even before the final rule was passed, including our healthcare policy team, finance, chief information officer and myself. This has been expanded to include our quality and regulatory leadership and our chief compliance officer, who also is the privacy officer. We also now include the chief medical officers from the hospitals.
Tran: We have an independent audit of IT for command and control. We look at standardization, backup procedures, disaster recovery and access. It is very helpful to me to have an outsider do the audit. They will show us some of the flaws before the real auditors come in from the federal and state governments.
Q: How has your board of directors reacted to the investment required to achieve meaningful use of your EMR?
Anderson: You've asked us questions about the return on investment, and we have struggled to point to hard dollars. We are getting the same sort of questions from our board members. They realize that this is a capital-intensive industry, but this is another huge wave of intangible investment. Board members wonder: What is this going to get us?
Tran: It all starts with governance structure. For us, we have the IT advisory committee, which is a committee of the board of trustees. They see our IT proposals from the beginning. They were really the advocates for us to get funding for our EMR. They know exactly what the dollars are and what is in it for the institution. We also have quarterly reports to the board and an annual report. This has worked well for us.
Q: The final question: What does the end game look like in five years?
Anderson: At the end of the day, this will deliver better healthcare. A well-deployed EMR will result in better, safer care and better public health. I think I am skeptical that we will get there on the government's timeline, but I do think it is the right thing to do.
Hudson: I think it has every opportunity to change the practice of medicine. What we know of today as the individual physician practice could become a thing of the past. There could be a resurgence of independent practice associations for the purpose of delivering this required technology.
O'Brien: There is now further insertion of technology into the exam room. We are rapidly moving towards a generation of patients who are more comfortable with technology. I think this will help patients become more engaged in their healthcare.
Fargnoli: When I go to my primary-care doctor or a hospital, I want them to know me. I want my health record in my pocket. I want control of that data. I don't believe it belongs to an institution. It belongs to me.
The biggest obstacles to achieving Stage 1 meaningful use are:
Implementing and sustaining CPOE, which requires a lot of ongoing technical support for front-line users.
Competing with neighboring institutions for the IT talent necessary to install and support an EMR.
Finding the money and personnel for extensive user training.
Ensuring that all components of your EMR are certified.
To learn more about meaningful use, visit Beacon Partners' website at www.beaconpartners.com or www.spotlightonhealthcare.com. To secure a free 2-hour consultation session on this topic, call Beacon Partners at 781-982-8400 ext. 7431.
The views expressed in "A Conversation with Beacon Partners" are not necessarily the views of Modern Healthcare or Crain Communications Inc.
