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Research by Lee Ann Jarousse

The push is on. There's less than a year to go for organizations to attest for Stage 1 meaningful use to receive the full set of incentive payments, but exactly how many will make it remains to be seen. According to a recent Healthcare Information and Management Systems Society survey, 41 percent of hospitals claimed to be well-positioned to meet Stage 1 requirements; however, 53 percent reported that they are not ready and 6 percent of organizations did not respond.

Thus far, the program has failed to meet expectations, at least in terms of the number of providers applying for incentive dollars and payments being made. The Obama administration orignally estimated it would pay out up to $2.8 billion during fiscal 2011, which ended Sept. 30. Between May (continued inside)
and December, 604 hospitals — including critical access hospitals — had received a Medicare incentive payment, totalling $1.109 billion. For all of 2011, Medicaid paid 1,043 hospitals $853 million. The first Medicare incentive payments were made in May; Medicaid started making payments in January 2011.

There are important lessons to be learned from organizations that have attested for meaningful use. "Stage 1 set a pretty high bar," says Chantal Worzala, director of policy at the American Hospital Association. "There's still a lot of work to be done to get all hospitals over the bar." Some of the challenges organizations face in meeting Stage 1 requirements are endemic to electronic health records adoption, while others are related to the actual regulatory requirements. The implementation and upgrading of EHRs is complex and time-consuming and many organizations are struggling with the compressed time frame set by the regulations. The workflow changes alone require significant education and training for clinicians.

Access to capital and workforce issues also are preventing some organizations from progressing. "It's a challenge for organizations to get the folks they need for meaningful use," says Worzala. Clinical informaticists, for example, are in high demand, and many are being hired away by consultants, vendors and other hospitals.

Vendor readiness is another issue. "We still have a supply-and-demand problem with vendors," says Worzala, noting that vendors are struggling to build meaningful use requirements into their products, as well as meeting all of the requests from hospitals and health systems.

The clinical quality measures have proved challenging for some organizations. The data requirements far exceed what most hospitals are currently collecting and many of the data elements still are being captured in written or dictated notes. Worzala notes that some of the clinical quality measures require sophisticated clinical judgment, such as when a stroke patient was last known to be well. Such elements are not easily captured in structured format, Worzala notes.

And it's not as if meaningful use is the only priority for hospitals and health systems. ICD-10 and health reform initiatives require significant investment and changes to information systems and processes.

It's important for organizations to approach meaningful use as a quality initiative, as opposed to an IT initiative, says Bob Schwyn, associate principal at Aspen Advisors LLC. "Meaningful use is … about transitioning data to quality of care," he says, adding, "Meaningful use is a journey, not a destination. The challenge is building a systematic approach to create an environment where data used for quality initiatives is available electronically."

Stage 1 critical success factors

Stage 1 establishes a technical platform to build a foundation for the meaningful use of electronic health records, with 2012 being the last year for organizations to attest for Stage 1 and still receive the full incentive payment. Below is a list of critical success factors in achieving Stage 1 meaningful use.



Proposed Meaningful Use Objectives and Measures for Stage 2

The Centers for Medicare & Medicaid Services have delayed the start of meaningful use Stage 2 until 2014. Below are proposed meaningful use Stage 2 objectives by the Health IT Policy Committee. CMS is expected to implement a final rule for Stage 2 in mid-2012.

Mike Mistretta | Vice president, information systems, and CIO, MedCentral Health System, Mansfield, Ohio

What are some of the biggest challenges your organization faced in attesting for Stage 1 meaningful use? Of the 14 core measures, which proved the most challenging to meet?

Our biggest challenge to meet Stage 1 was implementing the associated workflows to the clinical processes to capture the requisite data. Some areas were pretty straightforward, such as adding a field to our nursing assessment. Others were more challenging, requiring us to get a department up and running on portions of the system they previously weren't using. Some organizations may have challenges integrating the various applications in their environment. We've had a single-vendor strategy in place for some time and did not have that issue.

For the quality measures, we already had in place a fairly automated process to capture the information, so we were fortunate. Of those submitted, the emergency department measures were the most difficult because of the sheer volume of patients to abstract.

Other than the financial incentives, what benefits has your organization achieved under meaningful use? How has it changed clinical quality?

While we were not bad before, I think we have an increased focus on metrics for our projects and workflow changes. Stage 1 meaningful use in itself really hasn't done much to improve quality, but it sets us on a path to improve over the long haul. By getting more proficient at capturing metrics, we gain a better appreciation of the process changes needed to influence care and, ultimately, outcomes.
What links are your organization finding between meaningful use and health reform?

If one reads the tea leaves … , it is pretty clear that the electronic exchange of information is going to be a cornerstone. Meaningful use has these capabilities woven throughout, not to mention the only way to effectively manage many of the pay-for-performance measures is to have a comprehensive data set from all care providers, meaning a health information exchange capability must be in place.

Pam McNutt | Senior vice president and CIO, Methodist Health System, Dallas

What are some of the biggest challenges your organization faced in attesting for Stage 1 meaningful use? Of the 14 core measures, which proved the most challenging to meet?

I think the CPOE 30 percent watermark remains a barrier to entry for many organizations. But, even for sophisticated organizations, the biggest challenge in meeting meaningful use is reporting the quality measures. The Centers for Medicare & Medicaid Services did recently comment that the quality metrics may not be completely accurate because of changing specifications and data that may not be collected yet in one's system. Also, the measures to provide an electronic copy of a patient's record and discharge instructions sound easy on the surface, but can be quite tricky to track and produce in the formats and time frames required. 

What advice do you have for other organizations?

I recommend that organizations meticulously document their reports and back up materials demonstrating compliance with meaningful use and the quality metrics. I have created large notebooks that contain my vendor's reports and screen shots, in some cases to prove we accomplished the measures. You should be prepared to undergo an audit perhaps two or three years out, long after data may have [been] purged from your transactional system.