HIT in 2014: Portal Perils and Half-Built Houses

We do not know the extent of the trouble about to rain down on healthcare information technology, but it is out there, and will start pelting providers within weeks, not months.

A year from now, things will look different.

A year from now, ICD-10 will be paying the bills.

A year from now, Meaningful Use Stage 2 will be standard operating procedure for the considerable number of eligible hospitals and professionals who attested to Stage 1 in 2011 and 2012.

But between now and then, there is oh so much work left to do.

For some, peril will strike early in the year, as they realize the electronic health record software they bet on back then will still not be certified for Stage 2. We will see EHRs ripped and replaced. We do not yet know the extent of the damage about to hit healthcare, but it is out there waiting, and the peril will be upon providers within weeks, not months.

For others, achieving Stage 2 will feel more like death by a thousand cuts. That's what I hear from Laura Kreofsky, a principal advisor at Impact Advisors, based in Chicago, although Kreofsky hangs her hat in Portland, OR.

For two years, Kreofsky was Meaningful Use program director at Sutter Health. Now, at Impact, she advises other providers "while catching up on two years of sleep," she jokes.

"Organizations that are more mature on their EHRs, or have been using health IT for longer, may actually be more challenged in this measure than people who just went up on an EHR," Kreofsky says.

She illustrates the point by explaining that seven or eight years ago, when those providers implemented their EHRs, some standards now baked into Meaningful Use Stage 2 did not exist. "LOINC was something you kind of talked about, but nobody was using very robustly, and then all of a sudden you're in a place where you have to implement it, and you've got 12 years of lab data that's not LOINC-coded and you've got all these downstream interfaces, and you need LOINC for your lab results, which is one component of that summary of care record, so it has this cascading effect," she says.

LOINC is but one example. There are others. "It's the little things that quickly become big things," Kreofsky says.

Portal Perils
Some providers built what, at the time, was innovative portal technology. But in doing so, they deployed part of their EHR vendor's patient engagement portal, overlaid with data pulled from another source, overlaid with another user interface, and a different login procedure than the vendor's own, Kreofsky says.

"I'm not saying they're going to have to step back or rethink their plans, but they may have to," she says. "They may suddenly discover that they need to rework something that, while it's not broken, is not in compliance."

The ease with which some of these organizations attested for Stage 1 of Meaningful Use may have instilled a false sense of confidence, Kreofsky says.

I suggested, and she agreed, that the essence of good healthcare IT governance is being able to put out fires while at the same time performing the kind of rigorous risk analysis and systems analysis that keeps the bigger picture in mind.

Otherwise, you end up with something like healthcare.gov, a system that had all the necessary pieces in place, but didn't have the overall project management in place necessary to insure anything like success. "The challenge is that many of these analyses and potential reworkings are very time- and resource- intensive," Kreofksy says. "It's not like you just check a box."

Like Building a House
Analytics will remain another hot healthcare IT topic in 2014, but the pitfalls are considerable there too.

"Most organizations are really struggling to move beyond just pure retrospective operational analytics," Kreofsky says. "They're trying to figure out where they can deal with their existing vendors and where to supplement with other tools or technologies. They're wrestling with data integrity, and quite importantly, the right skill set for this type of work. I have seen some data points, heard some pain points, talking with clients. It's a different type of mindset from I'll say building order sets to understanding utilization trends."

I mention to her the widespread disenchantment I've heard from providers with the analytics technology they have been acquiring.

"You have to ask the question, why are you so disenchanted?" Kreofsky says. "It's probably a third or a fourth the product's problem. It gets right back to data quality, data integration, staff capabilities, and governance.

Kreofsky characterizes healthcare IT as being in an unfinished state. "My analogy is often one of building a house," she says. "You have to buy the land. You have to invest in all of the architecture. And this is all like pre-implementation planning, and then you put in the foundation and the frame of your house, and that's your EHR, and that's a lot of money."

Although providers want to move in to the EHR and settle down, they need to keep spending on the other parts and pieces to have a finished house in order to really get the full value of that house, Kreofsky says.

"'The challenge for CIOs and for organizations now is to recognize that the big capital spending era is over, but to continue investing appropriately to get the full value of the technology."

Fatigue May Set In
With $17 billion already handed out in incentive money for Meaningful Use, it's hard advice to hear. "Quite honestly, if we look ahead a year, we're going to be really tired as an industry," Kreofsky says.

"Everybody's going to have to push to get to Stage 2. We're going to be dealing with ICD-10, and there's going to be increasing pressure across the board for cost management, both capital and operating, so it then becomes incumbent for organizations to really look to find the value, the innovation, the return on investment, on things like analytics and patient engagement, population health."

ICD-10 will happen. It has to. Getting paid depends on it. But Kreofsky notes that if an eligible professional or eligible hospital fails Stage 2 MU in 2014, they would not attest and would not get their incentives for the 2014 reporting year, and they would be penalized—a 1% reduction in Medicare reimbursement—which would be incurred in 2016. That's the biggest looming threat.

It's no mere coincidence that Kreofsky used to train for triathlons with a CIO friend. Next year will feel like one too.