Electronic health records (EHRs) show promise to improve quality of care and patient outcomes—that’s why the federal government is investing billions of dollars in them. But data to quantify that potential has been inconclusive and sometimes controversial. Authors of a new study, published last week in theNew England Journal of Medicine, say they are among the first to offer hard evidence that in a head-to-head competition, electronic records beat paper.
The researchers tracked quality measures and outcomes for more than 27,000 Cleveland-area adults with diabetes and found that those who were treated at physician practices using EHRs enjoyed substantially better outcomes than those who were treated by doctors relying on paper records.
The more than 500 primary care physicians in 46 practices who took part in the study are all members of Better Health Greater Cleveland, a nonprofit healthcare alliance made up of providers, health plans, employers, and government agencies focused on improving the health of chronic disease patients in Northeast Ohio.
Outcome measures included meeting national benchmarks for blood sugar, blood pressure, and cholesterol control, as well as more patient-driven actions such as achieving a non-obese Body Mass Index and avoiding tobacco use.
Among the findings:
Nearly 51% of patients in EHR practices received care that met all four of the endorsed standards, compared to just 7% of patients at paper-based practices.
Nearly 44% of patients in EHR practices met at least four of five outcome standards, compared to about 16% of patients at paper-based practices.
After accounting for patient differences, EHR practices had annual improvements in care that were 10% greater than paper-based practices, as well as 4% greater annual improvements in outcomes.
Furthermore, it made no difference whether patients were insured by commercial payers, Medicare, Medicaid, or even if they were uninsured—all showed better results in standards of care and outcomes.
“Some of the rather dramatic differences that we’re showing are a function of sharing across systems and best practices with regard to common conditions and common metrics that we’ve all agreed to attack,” Greater Health Director Randall Cebul, MD, the study’s lead author, told HealthLeaders Media.
“There’s a lot of coaching that goes on. We say we share ideas and compete on execution. Electronic Health Records are simply tools. And the master craftsman will have a workbench with all the tools on it but knows how to use them and uses them in the right circumstances,” said Cebul, who is also a medical professor at Case Western Reserve University and practices at The MetroHealth System—both organizations are members of Better Health Greater Cleveland. “We are training one another in what the tricks of the trade are, in order to do better on the kinds of things that in an increasingly busy primary care practice could be overlooked.”
The study should pave the way for similar projects, said David Kaelber, MD, MetroHealth’s chief medical informatics officer, in an interview. “I hope that this is one indication that we’re really getting to the tipping point.
For decades this has always been the hope—that eventually technology will transform healthcare as it has other industries. We’ve poured in billions and billions of dollars. But to date the real value seen from that investment has been minimal. This is one of the studies that really shows that the value of that investment is significant. So I think there will be many more examples of this in the future.”
Other healthcare systems can replicate the study results, Cebul says. But “to replicate this study in a faithful way would require that you do it in an environment within which practices agree they’re going to improve the care and outcomes of people with specified conditions and specified metrics.”
The results of this research are just the “tip of the iceberg” when it comes to proving the potential for EHRs, Kaelber said. “The reality is that even though it’s a great study, we’re only looking at diabetes and several outcomes. The future of this is that we should be seeing more and more studies like this and outcomes like this, where the electronic health records really are transforming the way that healthcare is delivered.”
More physicians and practices can expect to avoid cuts in Medicare payments now that the Centers for Medicare & Medicaid Services has softened e-Prescribing rules.
In its final rule, published in the Federal Register Tuesday, CMS added new "significant hardship" exemptions, agreed to exempt those practices that are already meaningful users of certified EHRs, and extended the deadline to apply for those exceptions by one month to November 1, 2011 for the 2012 payment adjustment.
A 1% cut in fees for those who are not successful e-Prescribers will begin in 2012. Providers also face a potential 1.5% and 2% cut for 2013 and 2014, respectively.
The final rule takes into account provider comments to the proposed rules—specifically complaints that they were confusing, cumbersome, and duplicative.
"After we published the 2011 Medicare Physician Fee Schedule Final Rule last fall, we heard about additional circumstances that could keep physicians and other health professionals from being successful e-prescribers," Patrick Conway, MD, chief medical officer and director of CMS' office of clinical standards & quality wrote in a blog post on the final e-prescribing rules.
"For example," he wrote, "some providers weren't sure whether certified electronic health record technology that the Medicare and Medicaid EHR Incentive Programs require is also a 'qualified' electronic prescribing system as required by the Medicare eRx Incentive Program. [Other] providers brought up additional hardship situations that the 2011 MPFS final rule didn't address."
The final rule is "a positive movement in the right direction" toward consolidation and clarification, Mary Griskewicz, senior director of health information systems for the Healthcare Information and Management Systems Society said in an interview.
"The biggest issue was [that] the eligible professionals did not want to have to deal with the payment adjustment for 2012. We think there's an attempt here to do that. Given the current environment, the providers are still feeling squeezed overall. To have them go through the adjustment in 2012 really wasn't fair," she said.
The 2012 hardship exemptions in the final rule cover eligible professionals who:
Cannot electronically prescribe due to local, state, or federal law or regulation or have limited prescribing activity.
Are not a physician, nurse practitioner, or physician assistant as of June 30, 2011 and do not generally have prescribing privileges.
Are located in rural areas without sufficient high speed Internet access or in an area without sufficient available pharmacies for electronic prescribing.
Additionally, organizations that have already registered to participate in the Medicare or Medicaid EHR Incentive Programs and adopt certified EHR technology do not have to prove that they are successful e-prescribers, since that program already requires meaningful users have e-prescribing capabilities.
Aligning e-prescribing incentives and certified EHR technology is a good move, Sharon F. Canner, senior director of advocacy programs for the College of Healthcare Information Management Executives said in an interview."With previous legislation they have not been aligned so it's really important that they have done that," she said. "We hope that CMS will continue to move down this path in harmonizing across Health IT related programs—big underline under harmonization."
Despite the fact that the changes will give some providers a reprieve, CMS is touting the more flexible rules as a way to encourage more providers to adopt the technology and to make it easier for them to do so successfully.
"In particular, the changes will better recognize those circumstances when the ability of professionals to meet the eRx requirements is limited and when the requirements clearly pose a significant hardship," Conway wrote.
"We remain committed to the many benefits that come to patients with successful electronic prescribing, and we continue to encourage healthcare professionals to adopt this practice. However, we also can appreciate and acknowledge that this technology poses challenges to some providers. Changes in the final rule will help doctors and other healthcare providers in their efforts to become successful e-prescribers, ultimately leading to fewer errors and better care for patients."
In another attempt to make it easier for providers to apply for exemptions, CMS added an online tool to its site. Physician practices, however, still have to submit a written letter.
In a statement, The American Medical Association that CMS "has provided more flexibility under the exemption categories and that they have extended the deadline for physicians to apply for an exemption until November 1." But the AMA said it" had hoped for even greater flexibility, including an additional reporting period. We remain concerned that physicians will be hit with a penalty and are not being given enough time to comply with the e-prescribing program criteria to avoid this penalty."
The market for technologies that bring healthcare to patients instead of the other way around—mobile healthcare and telehealth—has been growing steadily. And many predict it will take an even bigger jump in the next few years.
That growth will be driven by a number of factors, including government initiatives and a trend toward collaboration between healthcare organizations and vendors.
The global mobile healthcare application market was $1.7 billion last year and it’s expected to reach $4.1 billion by 2014. And the global telemedicine market is expected to reach $19.5 billion by 2014, according to two separate reports released by Infiniti Research, a global market research firm based in London.
Some of the factors leading to the growth in these markets, according to Infiniti’s research arm, Technavio are:
A clear need
You know what they say about necessity being the mother of invention—there is a real need in developing countries and in rural areas here in the U.S. for better access to healthcare, and both mobile health and telehealth offer that access.
Some argue that there’s not much evidence that remote healthcare is significantly better than in-person care. But others contend that it is just as good if not better and that, in fact, remote health has an edge for its ability to ease physician and specialist shortages and save money. (Whether payers buy that argument is another story.
Better technology
Technology is advancing quickly in the mHealth and telehealth spaces. Vast improvements in audio and video capabilities, for example, make for more productive remote visits and more accurate remote diagnoses.
Government interest
The FDA is looking to oversee some mHealth apps that could be considered medical devices. Although an argument could be made that too much government oversight can stifle innovation, this step could lead to better quality medical apps. According to the report: "Proper rules" for the approval of mobile health applications will "increase the productivity and the accuracy of the Mobile Health applications in the future."
The FDA wants to oversee mobile medical apps that are used as an accessory to a medical device that it already regulates or that transforms a mobile platform into a regulated medical device. The FDA has already cleared a handful of mobile medical apps, such as a smartphone-based ultrasound and an application that allows doctors to view medical images.
Government money
Telemedicine equipment is expensive. But the feds are also driving growth with federal grants aimed at using telehealth to improve rural access to healthcare or healthcare app developer challenges encourage—and reward—innovation. Finally, remote care payment reform is slowly expanding Medicare reimbursements for doctors who monitor patients remotely in urban and suburban areas.
Strategic partnerships
Vendors have been partnering with or purchasing companies to secure their spot in the mHealth market, but increasingly they are working with healthcare organizations such as the Mayo Clinic and Meridian Health to develop healthcare apps. The telehealth industry has also seen a flurry of partnership and acquisition activity.
New tele-services
Remote radiology was one of the earliest examples of telehealth; remote or e-visits and remote or e-ICUs soon followed. A more recent trend toward remote surgery will also drive growth in the market, according to the report. "With the advent of advanced surgical techniques like Tele-surgery and robotic surgery, demand for image processing software and equipment is increasing," the report states.
"Moreover, for finer movements in surgeries, surgeons are provided with 3D glasses. In the future, sufficient bandwidth will be required to minimize the lag time in the audio-visual simulation in advanced surgical methods through tele-surgery."
Strong innovation
An increasing need, improving technology, and more incentives all lead to better and more futuristic technologies from developers. "The exponential growth of Mobile Health recently is encouraging many corporations to enter this industry," the Technavio report states. "Moreover, the existing companies in this fragmented market are coming up with a variety of innovative products in order to seek the first mover advantage in this domain."
RFID tags have for a while been used mainly for things—to keep track of the number of bandages left in the supply closet or to keep an expensive piece of equipment from walking out the door, for example. Increasingly, though, those badges are showing up on the lapels of patients. And hospitals are using the data those RFID badges gather to improve patient flow, shorten length of stay, and more.
Wilmington, DE–based Christiana Care Health System pins patients with RFID tags to track their movements throughout the continuum of care. The collected data is an "extremely powerful" tool for process improvement, says Linda Laskowski-Jones, vice president of emergency and trauma services for the two-hospital system.
The system tracks interval-level data—measuring the time a patient spends in between each activity—from the time they see a doctor to the time the doctor orders labs or an x-ray, for example.
Each department can see exactly where a patient is in the process—radiology gets an alert when the patient is ready for his or her scan, the doctor knows when the test results are ready and also knows where to find the patient to deliver those results.
The data also helps the organization spot wasted time and bottlenecks. It showed that a synchronous discharge model was more effective in the ED, for example.
And they've used the RFID data to reduce the time it takes to move patients into a bed. The tracking system and electronic bed-management system are interfaced: When staff post a patient for admission in the RTLS tracker, the information is automatically sent to the bed management system, alerting transport and bed management staff.
"It was the data from the tracker that allowed us to look at every interval that that patient went through and then start to ask if all of these intervals are necessary. Because every time they have to go through a separate, distinct process, there's a price tag," Laskowski-Jones says. "And the price tag is time."
Process redesigns like these led to another positive outcome—now the ED can now handle more volume. Fewer patients leave without treatment—a major cause of patient dissatisfaction.
Read more about the myriad ways organizations, including Christiana Care, Massachusetts General Hospital, and The Ohio State University Medical Center are using RFID and RTLS to keep small but expensive medical devices out of the Dumpster, prevent clinical technology "hoarding," and make nurses happier (hint: It involves saving them time) in the August issue of HealthLeaders magazine.
Also, learn how The Roy and Patricia Disney Family Cancer Center in Burbank, CA, uses RFID tags to track the location of its patients as they move through the system in order to improve their experience while there: Disney Applies Technology to Improve Patient Experience.
Several years ago I wrote about how an organization's Web site could improve the patient experience. Back then, making it easy to find phone numbers, directions, and other info on the site, creating doctor directories with profiles, photos, and video interviews, and perhaps offering some health-related content seemed advanced. Today it seems quaint.
In our most recent Intelligence Report, The New Patient Experience Imperative, we polled leaders at healthcare organizations to learn about their online strategies. The results, to say the least, were mixed. Some organizations are using advanced online tactics. But it seems like more are still pinning their patient experience hopes on outdated models.
We asked leaders to share their strategies for online communication and interaction with patients to enhance the patient experience. Most (45%) said they will update their existing website to assist and attract new patients. Meanwhile, 33% said they do not yet have a strategy in place.
"The patient experience more and more frequently begins online, and we know health systems and hospitals understand this because they invest in websites," Peter Kühn, CEO of Birmingham, AL-based MEDSEEK, which sponsored the report, wrote in an analysis. "But patients expect more than just information; they want to manage their care in their own time and on their own terms."
So how else can technology help hospitals engage patients? Other answers (respondents could choose more than one) offer some examples:
42% "will provide patients with an online experience that includes information from hospitals, physician practices, and other services"
36% "will retain existing patients by offering a patient portal for interactive services such as appointment scheduling and access to medical records"
34% "will use social media and networking sites such as Twitter and Facebook"
27% "will use mobile technology to facilitate patient care and communication"
We also asked about patient portals that offer advanced features to meet meaningful use objectives, such as providing lab results or discharge instructions. Although 33% said they have them, most (42%) said they don't have a patient portal at all--let alone an advanced one. Another 25% said their portal doesn't have the kind of functions that will help them meet meaningful use requirements.
That's not good news, according to Kühn. "Patients want to see lab results securely online. They want to download discharge instructions and access their health records without needing to schedule an office visit. They want to be able to schedule appointments online and conduct e-visits when an office consultation is unnecessary. And they want to do this without filling in the same forms again and again and showing their health insurance cards every time they walk into a healthcare facility," he writes.
"Providing access to lab results and discharge instructions will attract and activate patients who are increasingly aware of their role as healthcare consumers—consumers who are accustomed to accessing information in the palm of their hand."
In last week's column, I wrote about how small hospitals can prepare for future technology demands . This week I thought I'd share some comments about the future of rural organizations and health information technology from Tim Size, executive director of the Rural Wisconsin Health Cooperative (RWHC) in Sauk City, Wisconsin. RWHC has been pursuing its mission, to help keep quality care available, cost-effective, and accessible in rural communities through an array of shared services and advocacy agendas driven by a cooperative model, for 30 years. It has 35 member hospitals.
I interviewed Size for the HealthLeaders magazine cover story, The Hospital of the Future. As often happens with a source who's passionate about a particular topic, much of our long conversation didn't make it into the story. Here's some of what ended up on the cutting room floor:
Gienna Shaw: How can rural hospitals prepare for the future -- not just for the most pressing, immediate issues but to position themselves for long-term success?
Tim Size:The best advice I ever got was to “choose your parents carefully.” The second best, and only slightly more easily implemented, is to choose well the leaders you get to work with. I am fortunate to work in a state that is frequently ahead of the curve, solving tomorrow’s problems more often than reliving past complaints. Wisconsin has a business and non-profit culture that is particularly fertile for strategic alliances, both formal and informal.
GS: What are some of the ways rural hospitals in your state are doing that?
TS: Rural Wisconsin hospitals on their own and through RWHC have been actively engaged in the development of many statewide initiatives, including most recently what will become our state’s health information and health insurance exchanges. RWHC is developing a rural portal with the Wisconsin Health Information Organization, a data repository, in order to access one of our country’s most comprehensive sources of health claims information.
This will allow us to better understand physician performance and where there are opportunities for systemic improvement. RWHC and rural hospitals are at the table with the Wisconsin Payment Reform Initiative in order to help develop the next generation of payment models so that they will work for both urban and rural hospitals.
GS: How are the 35 RWHC member hospitals preparing for the increasing emphasis on health information technology and electronic health records?
TS: RWHC’s work in health information technology is just one example of what a rural network with strong member support can accomplish. Long before there was such a thing as meaningful use, RWHC was involved in developing telecommunication networks and facilitating electronic health record adoption.
Our main technology project has been the establishment of the RWHC Information Technology Network (ITN). This is collaboration between five of our member hospitals in which participants pool their HIT resources and access a common EHR system from our two data center locations. RWHC provides the shared staff that supports the hardware, software, and infrastructure.
We started this project a couple of years before meaningful use hit the stage, which was good timing. All five ITN members are well positioned to receive incentive payments this year.
GS: In what ways is your organization reaching out beyond the Wisconsin borders?
TS: The ITN helps a number of Wisconsin hospitals with hands-on HIT assistance, but we’re also working hard to ensure that other rural hospitals aren’t left behind in the HIT revolution that meaningful use represents.
We’re doing this both by advocating for regulations that take rural-specific circumstances and challenges into account and also by developing tools and resources to help all rural hospitals achieve meaningful use.
As part of the above work, RWHC’s QI program has just received ONC ATCB certification for meaningful use. It’s now one of only a handful of “modular” products nationwide that meets the QI submission requirements. The point is that we are focusing heavily on the intersection between information technology and quality, something that will be critical to all providers’ future success.
GS: And how can rural hospitals across the nation help themselves prepare for the future—especially in terms of government regulations, such as meaningful use?
The long-term strategy for rural hospitals must include becoming much more active as advocates for the people they serve–to assure that major federal policy initiatives have been thoroughly vetted for their potential impact on rural communities. In particular, CMS leadership and rural health leaders need to sit down and discuss how we can work more collaboratively in pursuit of many common goals.
We need to address the engrained attitudes on both sides that appear to have fueled too many initiatives from the current and prior Administration. Too many proposed regulations or comments have been seen as outright attacks on the very existence of small rural hospitals.
Do you think it's possible for small hospitals to remain independent in the long run? Or is it inevitable that the for-profits and large systems will take over?
TS: I don’t think any one corporate model is inevitable in our country given the value we place on independence, inventiveness, and the underdog. But it isn’t my place to say what a rural hospital should or will do with such a sensitive issue. There are many examples of both “independent” and “system” hospitals excelling at serving their local communities. We clearly are in a time of significant uncertainty. During such times, we see a spike in mergers and acquisitions in any sector.
GS: What are some of the specific trends that will help rural organizations find their place in the healthcare market landscape of the future?
TS: In the long run, there are at least four trends that I believe will continue to support locally based organizations as part of the mix.
First, all providers are increasingly incented to work collaboratively so the distinction is fading between independent and system.
Second, advances in telehealth and electronic support services will give local hospitals more choices in where and how they gain assistance in maintaining local care.
Third, the imperative and benefits of hospitals working with their communities to create health will definitely favor those with the strongest local connections.
And last but not least, health reform will tend to level the playing field between primary care and specialists (and their related hospitals). The overpayment of specialty services will be less available to fuel the corporate acquisition and subsidization of rural hospitals. I believe it is likely that we will see a healthier balance between the power of capital and the power of place.
The healthcare workforce shortage isn’t going to magically solve itself in the next decade. At the same time, job descriptions will be changing, and even top executives will need to update their skill sets. Healthcare leaders need to change the way they recruit—right now.
For starters, healthcare organizations have to get more aggressive when it comes to hiring, says Robin Singleton, head of healthcare practices for the recruiting firm DHR International. That might mean breaking with tradition. Hospitals don’t have to wait until physicians are in their second or third year of residency, for example. They can start wooing them in year one.
For rural areas, that’s all easier said than done: The shortage of healthcare workers has been “looming” for years now. In rural areas, it’s already here.
“Without immediate changes to the supply pipeline today, [the shortages] will reach crisis proportions in areas where the maldistribution of caregivers has always been a chronic problem,” says Tim Size, executive director of the Rural Wisconsin Health Cooperative, a professional services and networking organization that’s owned and operated by 35 rural acute and general medical-surgical hospitals.
With an eye toward staffing the hospital of the future, RWHC worked with the University of Wisconsin to create the Wisconsin Academy of Rural Medicine, a rural medical school within a medical school. The program is being expanded to create the rural residencies and training tracks needed to absorb the 25 students who will soon be graduating each year.
“We’re working with a statewide public-private sector consortium to develop the data and forecast tools we need to best inform how and where we modify workforce supply,” Size says. “And we’re working to implement hard policies regarding the total number of medical school graduates and residencies our state will need in 2030.”
Leaders should be writing job descriptions for positions that don’t yet exist, Singleton says. In the next five to 10 years, new healthcare regulations will call for new core competencies in a number of departments. IT staff must be well-versed in ever-changing clinical technology. Coding staff will have to meet the challenges of the expanded ICD-10 billing system. Revenue cycle staff will need to be adept at managing self-pay accounts. Physicians and nurses will have to get fully immersed in CPOE and other electronic medical records modules.
Executive job descriptions will change, too, as organizations seek leaders who can develop and lead accountable care organizations and respond to other business challenges.
The hospital CEO of the past was focused on attracting patients and getting physician referrals, says Kathy Love, CEO of Clark Regional Medical Center, a 79-staffed-bed hospital in Winchester, KY. The CEO of the future must be able to manage patient populations collaboratively and form partnerships with physicians and other providers along the continuum of care.
“The days of the ego-driven hospital CEO are over. You have to be relationship-driven—sometimes with the people you once considered your competitors,” Love says. “It’s not all about your hospital anymore; it’s about how your hospital fits into the larger system”
This piece accompanies The Hospital of the Future cover story in the July issue of HealthLeaders magazine.
“Hospitals should be looking toward strategic investments to meet their market needs in areas that will ultimately improve outcomes, reduce length of stay, and reduce costs,” Love says. “You’ve got to look across your service lines at what drives cost, patient delivery, bad outcomes, and the ability for the patient to recover faster and better and do everything you can to get there.”
Clark Regional Medical Center has recently invested in advanced laparoscopic equipment, for example, because minimally invasive techniques reduce LOS and recovery time. “We have to be aggressively looking at new surgical techniques and move as fast as we can toward cutting-edge technology that really affects patient outcomes,” Love says. “You can’t be the one that sits back and is the last adopter.”
Radiology is another service line where investment now will pay dividends in the future, in part because of its potential to replace some invasive diagnostic procedures, such as those in the cardio space. Because imaging is noninvasive, it can also cut down on infections and other quality concerns.
That’s true at even the smallest of organizations.
When the 25-staffed-bed Elizabethtown (NY) Community Hospital conducted an analysis of its technology infrastructure, the radiology department—with its old, hand-me-down x-ray equipment—quickly emerged as a space with a lot of unrealized potential. It was also a chief source of complaints from physicians who felt imaging tests simply weren’t reliable, says CEO Rod Boula. “That’s lost business,” he says.
The radiology department is now fully digital.
“I can remember the days when we didn’t have a fax machine. On the care side you didn’t have CT scanning as part of primary care—that was for the big hospitals. Now we’re seeing it become more of a primary care tool,” Boula says.
Telemedicine is another technology that’s particularly well-suited to smaller organizations. Specialists once traveled to Elizabethtown to see a handful of patients when they could have stayed in their offices and treated dozens instead. “It’s not efficient,” Boula says. “They’re saying, ‘Look, from a business perspective I can’t do this any longer.’ So we lose the service.”
And now tiny Elizabethtown can offer its patients access to specialists across the country or around the world.
Many small hospitals are early adopters of technology such as telemedicine because they are innovative by nature, says Jane Hooper, director of community relations at Elizabethtown. After all, they have to be.
“They’re in a small community; they are miles away from other healthcare organizations; they have patients who need access to specialty physicians; they need access to digital mammograms, for example. And we figure out a way to make it work. We just find a way to make it happen—providing these people with the care they need.”
“It’s not a question of can we do it; it’s question of how,” says Elizabethtown CIO Brett Sicola. “We have to make this happen. You’re going to come up against obstacles. Figure it out, work your way through, come up with a plan. We will get there, step by step.”
One step in the plan for Elizabethtown is to purchase technology with an eye to the future. The organization has more telemedicine units than it can use on a regular basis and it definitely has more fiber-optic connectivity than it needs. For now, at least. An early investment in smart pumps with wireless connectivity is one example. “We couldn’t necessarily take full advantage of that today.
It is used for drug updates to the libraries; it is used to send information to a centralized reporting server—someday, when we’re ready, we’ll integrate with our EMR,” Sicola says. “One step at a time.”
“We want to have as many things in place as we can so that when opportunity presents itself we’re ready,” Hooper says. “We’re getting technology purchased and installed and ready ahead of time so that when things change in the future or we need to add things in the future we’re already ready to go.”
“We have products that will grow with us in the future,” Sicola says. “Part of our strategy has been implementing health information technology that fits our culture, fits our business model, and is compliant with all of the standards,” Sicola says.
Last February I asked every CIO I could corner at the annual Healthcare Information and Management Systems Society meeting what his or her organization was doing to prepare for ICD-10.
I got a lot of blank stares.
Sure, the deadline for the massive coding switch-over isn't until in October 2013. But I got the sense that even if folks weren't quite ready to brag about their progress preparing for ICD-10, they were at least starting to think about it with greater urgency.
A new Intelligence Report from HealthLeaders Media, ICD-10 Puts Revenue at Risk, backs that thesis: 84% have started their ICD-10 projects. Meanwhile, less than a third (29%) have moved beyond the assessment phase into implementation.
Of the organizations that have begun their assessments, 73% have completed a system/vendor readiness analysis; 64% have assessed training needs; 57% have done a documentation gap analysis; and 48% have completed a financial impact assessment.
That's worrisome, says Albert Oriol, vice president and chief information officer at Rady Children's Hospital and Health Center in San Diego and lead advisor for the report. "Anyone who isn't at least partway through [discovery/assessment] is behind," he told HealthLeaders Media's Senior Finance Editor Karen Minich-Pourshadi. She examines the financial jitters ICD-10 is causing.
Oriol notes that without the assessment,organizations may be caught off guard by a bigger-than-expected price tag. "The cost is higher than they may think. We did our financial assessment and now we're discovering that it's double what we estimated," he says.
The survey suggests there's confusion about the cost of converting to ICD-10. Of those organizations that have completed the financial assessment, 32% expect to spend up to $1 million to prepare, while just 9% estimated a cost between $1.1 million and $5 million. Only 1% of respondents project an implementation cost between $5 million and $10 million. More than half either were uncertain about an estimate or had not completed one.
Those numbers "seem a little light," John Dragovits, CFO for Dallas-based Parkland Health and Hospital System, says in the report. Most organizations will fall into the $1.1 million–$5 million category, he predicts, while the cost to larger organizations such as his 720-bed system could exceed $5 million.
Regardless of where respondents were in the ICD-10 process, many said they expect to take a substantial revenue hit.
Of the 46% of respondents who expect revenue losses associated with ICD-10 implementation, 28% anticipate revenue loss between 6% and 10%, with another 12% expecting revenue losses at between 11%–20%. Nearly a quarter (23%) of respondents expect those losses to last one to two years, another 6% think it will be more than two years, and 7% expect the losses to become permanent.
Despite the immediate revenue hit, many organizations do expect that the ICD-10 conversion will ultimately pay for itself, with 25% estimating one to two years before achieving ROI. Still, 27% of healthcare leaders say they don't ever expect a return on the investment, and 26% are unsure.
In the report, Oriol closes with an interesting point: Healthcare leaders think the cost of implementing ICD-10 will be low and the potential loss of revenue will be high. So, he asks, why aren't hospitals getting on with it?
In the 1990s, big bang rollouts of electronic health systems were all the rage. But have you ever heard the phrase "only fools rush in?" Many organizations learned that while that approach got complete systems up and running, it didn't guarantee that clinicians would like them.
So the industry tried a more drawn-out approach, forming vast committees to get buy-in from every last stakeholder. In the end, though, that didn't guarantee adoption, either. In fact, it created new problems, such as alert fatigue.
Today, organizations are finding a balanced approach to launching systems such as computerized physician order entry that lets them get buy-in and get to go-live faster and more efficiently. I spoke to leaders at several organizations in various stages of implementing CPOE for an article in this month's issue of HealthLeaders magazine. They offered the following five steps to successful CPOE:
1. Pare down committee rosters.
When everyone in an organization has a hand in reviewing, revising, and creating order sets, they tend to get a bit complex. And it takes an awful lot of time. Some organizations are trying a decentralized approach to creating order sets. A small, multidisciplinary advance team gets the order sets to about 80% completion and then turns to specialists to finish them up.
2. Get the right people at the table.
Michigan-based MetroHealth system used the decentralized approach, creating a CPEO team that included senior leaders, physicians, nurses, IT staff, and representatives from other departments, such as lab and radiology.
It's important to ensure that each department agrees to a representative model, says Bradley Clegg, DO, chief of medical informatics. Given the choice between attending every single meeting and having a delegate do the initial work, most will happily choose delegates.
3. Streamline meetings.
No matter how you cut it there are going to be a lot of meetings leading up to a successful launch of CPOE or any other big HIT project. Asynchronous forms of communication—such as online document sharing—allow team members to log in and read the proposed sets, make comments, and interact and collaborate with the entire team. Allowing them to do this at their own convenience can cut way down on meetings and make the process more productive, Clegg says. Setting comment windows at just one week can also speed things up. And consider imposing time limits on meetings.
4. Get the message out.
Investing some time up front can lead to faster implementation on the back end. And messaging is key, says Jeremy Theal, MD, director of medical informatics at North York General Hospital in Toronto, Canada. He sent clinicians data from study after study with examples of evidence-based best practices in various fields. "I showed them [CPOE] will make a bigger difference to patient care than even some of the medications that are coming on the market," Theal says. "And not only that—it will cost less."
5. Take baby steps.
Starting physicians with a modified CPOE tool can aid with adoption. For example, some organizations have PDFs of order sets available on their intranets. Physicians can log on, fill out the form, print it, sign it, and handed it to the unit secretary. Although the result is still a paper document, it gets them used to using a computer for the order process. When it's time to flip the switch to "real" CPOE, physicians will no longer have to print and sign the forms—they'll just click a button to submit. Because there's one less step in their process, physicians actually will perceive CPOE as an improvement in workflow—not a small feat.