Hospitals with electronic health records (EHR) may be eligible for meaningful use incentives as early as October 2010, and physicians follow soon after. What if a provider is hoping to take advantage of the incentives, but is still fully paper-based? Waiting for the release of final rules on the incentive program and EHR certification before moving forward may not be wise.
Providers should begin by looking into the reasons their facility doesn't have many of the components that make up an EHR, or lacks an electronic system altogether. For example, if providers haven't begun to invest in a system because of high up-front costs, they may be able to obtain funding that can help.
"Right now, there is a significant amount of money that is being funneled through the states for health IT," says Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, OR. Depending on their location, healthcare providers may be able to take advantage of it.
"Go to the medical association in your state that you're a member of, and put a little pressure on them," he says.
If your state has grant or loan funding available, remind your association that there is money available and encourage them to lobby and partner with others to push your state to start allocating EHR funding, whether it happens to be low- or no-interest loans or outright grants.
If your state is not offering funding, there may be other programs you can find that offer no- and low-cost loans and other programs to provide support and consultative assistance, especially for small hospitals and physicians, says Margret Amatayakul, RHIA, CHPS, CPHIT, CPEHR, FHIMSS, president of Margret\A Consulting in Schaumburg, IL.
Smaller providers may also want to look into independent physicians associations (IPA), some of which are purchasing EHRs and making them available through a subscription fee. With this option, you have your own Web-based version, and you pay the IPA a certain amount annually to host the EHR, explains Apgar.
"This can be affordable because you don't have to go out and buy a brand-new system and implement it and have someone administer it and all that," he says. "You're paying a subscription fee to use it, in essence, so you don't have the cost of ownership."
Remember, however, that subscription-based EHRs may end up costing more in the end, even though they are becoming more common, Apgar says.
If you are still searching for an EHR vendor, don't forget about the big picture. With additional requirements coming soon, whether additional meaningful use measures or other capabilities your EHR will need to be ICD-10 compliant, look for a product and vendor that will be able to keep up.
"If you are in the position of buying a product today, you want to be buying a product that is going to take you through those stages," Amatayakul says. "My sense is that you approach this by trying to address the long haul. Otherwise, you're going to be faced with pieces of things that don't work together real well."
And avoid vendors who don't have a sense of the upcoming changes and how they plan to address them.
"If there is little to no understanding on the part of the vendor as to what this means, or the vendor can't describe for you what they plan to do, I would avoid that vendor," Amatayakul says. "That means they're not going to be able to keep up."
Is your EHR meaningful use-compliant? Healthcare providers may soon be able to find out for sure.
HHS released a proposed rule Tuesday for establishing certification programs for health information technology. The proposed rule describes the creation of a certification program for EHRs, as mandated by the HITECH Act.
EHR certification is designed to "give purchasers and users of EHR technology assurances that the technology and products have the necessary functionality and security to help meet meaningful use criteria," according to a press release from the Office of the National Coordinator (ONC) for Health Information Technology.
When writing the interim final rule on standards and certification criteria for EHRs, the ONC strived to balance competing agendas, David Blumenthal, MD, MPP, the national coordinator for health information technology, said today at the Healthcare Information and Management Systems Society (HIMSS) 2010 Annual Conference and Exhibition in Atlanta.
For example, it tries to balance the need for uniform standards against the need for interoperability and innovation and the need for an efficient way to exchange information versus patients' rights to privacy. The agency tried to allow for flexibility, to meet providers "where they are," and not inhibit "critical innovation," he said.
The first phase would be a temporary certification process whereby the National Coordinator would approve organizations to test and certify EHRs.
The eventual permanent program would transfer testing and certification fully to private sector organizations and separate the two functions.
The separation of those two functions is an important aspect, Blumenthal said. It allows certification of not only completed EHRs, but also of individual modules, a move designed to allow architectural innovation.
The proposed permanent program also has requirements for accreditation and addresses the potential certification of health information technology (HIT) other than complete EHRs and EHR modules.
HHS anticipates issuing separate final rules for each of the two programs.
The multi-phase system is designed to enable eligible professionals and hospitals to implement certified EHRs in time to qualify for the initial set of meaningful use incentives, which are set to begin as early as October for hospitals, and January 1, 2011 for eligible professionals.
The phased method is a sound way for HHS to work within the regulatory timelines put in place by the HITECH Act, says Frank Ruelas, director of compliance and risk management at Maryvale Hospital and principal of HIPAA Boot Camp in Casa Grande, AZ. "It's an ambitious program, so this approach works well."
Because HHS made such a conscious effort to solicit input from so many different parties and such a wide variety of stakeholders, it injected an element of practicality into the rule, according to Ruelas. In addition, the rule takes care to consider the evolving meaningful use criteria and how the adoption of future criteria may affect the certification status of EHR systems or modules, he says.
One element of the program the healthcare community is likely to find particularly helpful is the proposed master "certified HIT products list" that the ONC plans to have publicly available on its Web site.
"This ONC master list will help folks accurately identify genuinely certified products that may help meet their needs, such as in achieving meaningful use," says Ruelas.
The ONC expects it will add additional features to the Web site over time, such as interactive functions that would allow providers to review combinations of certified EHR modules to verify that they would comprise a certified EHR technology.
Interested parties will have 30 days after the proposed rule's publication in the Federal Register to comment on the proposed temporary program, and 60 days to comment on the proposed permanent program. You can submit comments electronically at www.regulations.gov.
Blumenthal made it clear that HIT leaders must step forward to provide feedback for the proposed rules; throughout the document, there are questions directed at HIT leaders and requests for feedback. "We want you to continue to be leaders and we will follow your lead," he said.
With the release of the proposed rule, the focus now shifts from policy to the process of implementation, said Blumenthal, who expects the release of the three related EHR meaningful use final rules later this spring. His soon-to-be expanded office will now begin working on the next iteration of meaningful use.
"That is a huge job. We are going to have to grow considerably to make that happen," he said.
Editor's note: For more information, visit the HHS Web site. Several helpful documents are available, including a list of FAQs and a Fact Sheet regarding the proposed rule.
HHS announced the release of the proposed rule for establishing certification programs for health information technology today. The proposed rule describes the creation of a certification program for EHRs, as mandated by the HITECH Act.
EHR certification is designed to "give purchasers and users of EHR technology assurances that the technology and products have the necessary functionality and security to help meet meaningful use criteria," according to the press release.
The proposed certification program will involve two stages:
A temporary certification process whereby the National Coordinator would approve organizations to test and certify EHRs.
The eventual permanent program would transfer testing and certification to private sector organizations.
"Publication of the proposed rule on the Establishment of Certification Programs for Health Information Technology is an important first step in bringing structure and cohesion to the evaluation of EHRs, EHR modules, and potentially other types of health IT," David Blumenthal, MD, MPP, national coordinator for health information technology, said in the press release.
In response to the proposed rule, Alisa Ray, executive director of Certification Commission for Health Information Technology (CCHIT), said CCHIT is confident about its prospects of becoming accredited and called the announcement "an important step that will reduce the uncertainty that the healthcare community has experienced while awaiting this additional information.
"CCHIT has four years of experience testing and certifying EHRs, and promptly adapting our testing to the latest federal standards. We have also been benchmarking our operations against best practices for certifying bodies, including the ISO/IEC accreditation standards, and we are well prepared. We plan to file an application with ONC as soon as they are ready to accept them."
The conversation continues regarding the effectiveness, appropriateness, and reasonableness of the EHR meaningful use criteria proposed earlier this year.
The committee's comments and recommendations include the following:
1. The committee disagrees with the proposed rule when it states that electronic progress notes are not directly related to improvements in patient care, quality, safety, or efficiency. The committee believes this is true for many reasons, including that handwritten records take additional time to decipher and are often illegible, and because it believes hybrid record systems "cause fragmentation of the record and inefficient workflow." For these and other reasons, the committee suggests the final rule contain an explicit requirement to include progress notes as part of the EHR.
2. The committee found that after reviewing the proposed core measures, none met its criteria for inclusion and thus recommends removing the proposed Stage 1 core measures.
3. The committee believes providers should maintain updated problems, medications, and allergy lists, but the proposed one-time reporting measure doesn't adequately demonstrate meaningful use. It notes that CMS could audit randomly selected charts instead of requiring a single report.
4. The committee believes that eligible professionals (EP) and hospitals should report on "the percentage of patients for whom they use the EHR to suggest patient-specific education resources," and that EPs should also report on "the percentage of all medication entered into the EHR as a generic formulation," when applicable.
5. The committee suggests that while the proposed meaningful use requires EPs and hospitals to implement five clinical decision support rules "relevant to specialty or high clinical priority, including for diagnostic test ordering," this language should be amended to highlight the importance of efficient diagnostic test ordering by requiring that at least one of the five support rules address diagnostic test orders
6. The committee recommends expanding the proposed measures for the preventive/follow-up reminders criterion to more than just patients older than 50. However, the committee does allow for provider discretion regarding the focus of those efforts, such as for a chosen preventative service.
7. The committee recommends that the final rule clarify the definitions of transitions of care and relevant encounters.
8. The committee believes the meaningful use incentive program should "contain some inherent flexibility," and "recognize providers who make good progress" toward meeting Stage 1 meaningful use criteria, even though they may not meet all of the requirements. Therefore it recommends that providers be permitted to defer fulfillment of a small number of requirements until Stage 2 criteria apply.
The proposed rule is open for comments through March 15. The final rule is expected in late spring.
It has now been a month since the CMS and the Office of the National Coordinator for Health Information Technology published the interim final rule for EHR certification standards and the proposed rule on the EHR Meaningful Use Incentive Program and meaningful use standards. Another rule proposing the EHR certification process and organizations designated to conduct EHR certification is also expected early this year.
But with incentive payments set to begin in October for hospitals and in January 2011 for physicians, waiting for the release of final rules before worrying about meaningful use standards may not be wise—especially for those hoping to take advantage of the early incentives.
"Despite the fact that there may be some changes, it is time to move forward with enhancements to your information systems that make sense for your organization," says Margret Amatayakul, RHIA, CHPS, CPHIT, CPEHR, FHIMSS, president of Margret\A Consulting in Schaumburg, IL.
So what can you do now to prepare? Much of this depends on how fully you have implemented your EHR and the functionality of the EHR you implemented.
Either way, now is the time to begin, even if some of the legislation is still only proposed. Certainly, CMS may tweak some of the measures for meeting meaningful use, says Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, OR. But he doesn't expect huge changes to the criteria themselves.
For example, one way of measuring whether meaningful use is occurring is through the maintenance of an active medication allergy list by the provider. At least 80% of patients seen by the provider or admitted to an eligible hospital should have at least one entry, or an indication that the patient has no medication allergies, recorded as structured data, says Apgar. "That may change," he says. "Not the criterion itself, but the percentage. They may decide to start off at 50%, for example."
If you already have components of an EHR, talk to your vendor because it will need to start reprogramming and give you a meaningful use–compliant upgrade once the certification final rule arrives this spring.
And ask the vendor about timing. "The vendor can give you an estimate on how much time it is going to take to make the changes to the application, but your vendors are likely not going to start making programmatic changes until that rule is final," Apgar says.
Timing could get tight in the fall for those hoping to catch the first meaningful use incentive payment. You can try to get an estimate as to the timing of available upgrades from your EHR vendor. For example, if your vendor needs a few months to prepare an upgrade for you after the final rule comes out, you may have difficulty implementing the upgrade in time to take advantage of the first opportunity for earning incentives.
"You may be looking at six months to a year implementation time, and then at that point you can start saying you're doing meaningful use," Apgar says. But taking even six months may mean you aren't eligible for the incentive payments until 2011 or 2012.
Also, note that vendors can't really predict how long it will take to certify their applications because that information is not yet available from the government.
In addition, remember that although the Certification Commission for Health Information Technology currently offers its own EHR certification, it is not necessarily going to be an official certifying body. "Right now, it is good to make the assumption that no EHR is certified," says Apgar.
But there are also plenty of tasks you can do now without your vendor that will help down the road, says Amatayakul. For example, you can circulate the proposed meaningful use measures among staff members to orient them as to what will be expected.
In addition, start to consider the level of effort and costs involved in upgrading, says Apgar. When calculating costs, don't forget to include staff disruption and training, not just the price tag on the upgrade. "Look at it from a total cost perspective," Apgar says. "Ask yourself, 'Is this really worth it to me right now?' And then look at budgeting. How are you going to pay for this? What is going to happen in terms of disruption of business? Will you need to bring in extra people?"
When you do decide to upgrade, don't forget the big picture—why you're doing it in the first place. As you update your system, that's also a great time to try to improve work flow or make process changes, Apgar says. You don't have to configure your upgraded system to the way you've been practicing medicine. "If you're going to make the investment, now is also the time for business process or clinical practice reengineering," he says.
Even without upgrading, many providers may be able to get better value out of their existing EHR technology. "We have an awful lot of people not using it as it could be used," Amatayakul says.
Just getting started with your transition to an EHR? Consider these tips from experts in the field as well as some of the providers who've been in your shoes:
"Don't buy (or build) a Cadillac when a Volkswagen will do," says Chris Simons, RHIA, director of utilization management and HIM and the privacy officer at Spring Harbor Hospital in Westbrook, ME. Staff members at Simons' hospital were naturally excited about all of the options available to them. But it meant that they sometimes built dictionaries (i.e., choices in table format) that were too complex. Staff members then had a very difficult time using them, she says. "You don't have to use all the bells and whistles at the beginning," Simons says. "Keeping it simple and focused will give you a better product and much happier end users."
"First things first," says Darice Grzybowski, MA, RHIA, FAHIMA, president of HIMentors, LLC, in La Grange, IL. "When getting ready to plan for implementation of your EHR system, make sure you leave plenty of time for planning the most important component of your system—your [electronic document management system (EDMS)], which should encompass both document imaging and HIM workflow support." This includes release of information, coding and abstracting, Master Patient Index management, work queues, and reporting. Take adequate time—at least six months—to ensure that your medical record forms are properly identified by barcoding for indexing and queue control, says Grzybowski. "This way you make sure that whatever system you use, you won't have to add additional staff for clerical support, and your efficiency, productivity, and quality processing will improve," she says. This strategy helps you avoid finding yourself trapped in a hybrid or fragmented system that forces you to split your legal health record into various source system components for access, says Grzybowski.
"Get involved early and stay involved through the implementation and after for all of the upgrades," says Tricia Truscott, HIM director at Carle Foundation Hospital in Urbana, IL. "Make sure you are trained prior to any upgrades and have an HIM advocate on the implementation team if possible." In addition, if you can, Truscott suggests you upgrade to double computer screens as much as possible.