Rules of the road

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). ICD-10 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 challenges 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.

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%.

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%.