Archive for Meaningful Use

Strategic Square Pegs

Now that we have the final rules for incentive payments and meaningful use, we reach a fork in the road. Healthcare leaders who take the time to look up from the day’s checklist of things to accomplish may realize that there are two ways to approach the required implementation of technology.

First is the path of compliance. This strategic approach asks:

  • What is the minimum we must do to get the incentive money and avoid penalties?
  • What hardware and software will get us there?
  • Can our IT department handle it or do we need more people?
  • How can we pay for it?
  • What is the deadline? Can we wait or should we do it now?
  • Etc.

Second is the path of control. This strategic approach asks:

  • What would the ultimate healthcare delivery system look like?
  • How would patients, physicians, nurses, operations, the organization and the community benefit?
  • How long would it take to get there?
  • What kind of information is required to get there?
  • How can we leverage the best qualities of technology to help us get there?
  • Etc.

Many will take the path of compliance, and realize later that despite a technically competent implementation, the organization did not adapt to the technology, and that the expected performance has fallen short. An organization should not adapt to the technology for one simple reason: its limits of performance and innovation are dictated by the technology.

So this is the time to engage the imaginations of everyone from the board to the support staff. Ask: “How could we improve everything?” Through this process each stakeholder will be expressing the value that could be had with the thoughtful implementation of information technology. If you design systems that provide that value, everyone will have something to gain.

The point here is that implementing health information technology is not purely a “technology” initiative. It is an initiative that starts with a vision of where your organization is headed. Yes, this is a big deal, but it is also a huge opportunity to see beyond the requirements of “meaningful use” and mere compliance with the evolving regulatory landscape. Look at meaningful use as a minimum of what you could accomplish with technology, and realize that the HITECH provisions of ARRA are not designed to get you much further than the minimum. By choosing the path of control, you design the process, and then build technology to support it. If your ideal process features round holes, design your technology as a round peg. Otherwise, all the pounding will result in more headaches down the road. Mostly for you.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Final “Meaningful Use” Rules Seen

The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) announced the final rules for meaningful use , incentives, standards and certification today. The requirements to qualify as a meaningful user of EHR technology, and therefore receive incentive payments as defined in the HITECH portion of the American Recovery and Reinvestment Act (ARRA), had been the subject of hot debate over the past year as providers wondered whether they could actually meet the terms set forth in the proposed rules seen earlier this year. The final rules do scale back the number of objectives that must be met somewhat, and provide more flexibility for providers to continue along individualized paths to meaningful use. Hospital systems that share a CMS Certification Number (CCN) will be disappointed to learn that the payments will still be made based on the single number, not as individual hospitals. This could mean millions to some systems, which are no doubt investigating how to separate their operations under multiple CCNs. The hospital-based physician definition was clarified to exclude physicians performing all work in an inpatient hospital setting or emergency room.

ONC is still the process of identifying organizations that will be certified testing and certifying bodies, but it projects that certified software will be available for purchase by this fall. Registration for the incentives begins in January, 2011, and be managed online by CMS. Attestations from providers seeking incentives will be made starting in April, 2011, with payments starting in May, 2011. Medicaid payments will occur on schedules dependent upon individual states and the status of their plan and progress made.

The final rules on meaningful use and the incentive program will be published in the US Federal Register July 28.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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From Trust to Reliance

Yesterday I noted how deeply the concept of trust is intertwined into everything we do in healthcare. It really creates a web of interdependent individuals, organizations and systems, each of which must trust that the other is effectively carrying out its role in the overall delivery of healthcare. Now the Leapfrog Group has issued a report summarizing the results of its computerized provider order entry (CPOE) evaluation tool. The data gathered between 2008 and 2010 will be of interest to anyone wondering whether CPOE should be included in the first level of meaningful use. According to the report, over 200 hospitals tested their CPOE systems to see if they caught common medication errors, including those that could be fatal. On average, the systems missed about one-half of the routine medication orders and a third of the potential fatal orders.

Leapfrog recommends testing and monitoring for all technology adoption, and that best practices are shared more transparently. “Competition is healthy, but in the case of IT adoption, collaboration is far better” the group notes. The group further recommends more implementation of CPOE, which can, when set up correctly, reduce medication errors. Fair enough. And now some questions:

  • How do we determine the best practice? Are there “flavors” of best practice for different demographics?
  • How can that best practice be represented and supported by our technologies in an efficient way?
  • How can we keep it current?
  • How do we begin moving from “having CPOE is good” to “having good CPOE is better”?
  • How can we integrate and begin to depend upon technology that is still evolving while maintaining quality in a high-risk, high-stakes environment?
  • Is it ethical to use technology to support patient encounters when we know the technology is still in its infancy?

The last two questions are most interesting, and probably the most challenging. On one hand, we are trying to create technical support systems that can reduce risk and alleviate some of the burden by transferring some of our knowledge responsibilities to the technology. On the other hand, we add to the risk and the burden because we must ensure that this technology mentoring process does not result in lower quality care, or deaths. In short, how do we know when it’s okay to begin trusting our systems? And coming to trust our technology is not the same as coming to rely on technology. Trust is a forerunner to reliance, and it holds true for the patient – physician relationship too.

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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Summers in Suspension

Last year at this time we were waiting for the final meaningful use recommendations from the policy committee. Even then (a year in HIT time seems like 10) we felt the pressure of the looming deadlines for achieving meaningful use. This summer, we’re waiting to see what the final rules look like. Depending on your point of view, they were either scheduled or promised for release by late spring, 2010. Now spring has passed, and even the government websites are have added “early summer” to the possible delivery date. Even when we do have the final rules, every product still needs to be certified, or re-certified, and we still don’t know who will be doing the certification. But worrying about all of that can ruin your summer, so instead I’ve been thinking about the concept of trust, and how much of what we envision as a result of HIT involves trust.

For example:

  • Physicians and patients might ask: Does the software work as promised? Are there any hidden problems that could jeopardize safety?
  • The government might ask: Are the end users acting in good faith? Are they using the system? Using it as designed? Or are they implementing workarounds?
  • Everyone is asking: Will the meaningful use rules increase the chances that most providers can achieve them?
  • Providers wonder: Will the government pay the incentives or look for ways to save?
  • Everyone asks: Are the systems secure?
  • Patients in particular wonder: What will employers and payers do with the data they have?
  • There are others…

We must also trust ourselves to adapt. It’s interesting that for years, the healthcare community has been aware of the fact that it is way behind in the adoption of technology to improve safety and delivery. The number one issue in just about every poll ever taken on the issue declared that the cost of these systems was the limiting factor. After all, technology is expensive. Now, the government is putting some money into softening the blow of the cost; that’s good! But that positive move has been dampened by the apparent rush to move everyone along at the same speed.

In project management, it is often said that of the three interlocking components (cheap, fast and good), you can only have two. A single implementation at one hospital is a complex undertaking; now multiply that times 5,000 hospitals in the US, factor in the half-million or so physicians who may or may not participate, and then tie it all together with the promise of one interoperable, trustworthy system. Do we trust ourselves, as a sector, to make the right choice? Which will we give up: Cheap, Fast, or Good? While the US is making a net investment in EHRs of about $17 billion (the actual initial investment is $30+ billion), consider that there are individual hospitals that have already spent hundreds of millions of dollars to get where they are today.

It’s great that we’re finally moving forward. But by making “meaningful use” the centerpiece of getting the incentive payments, the focus shifts to the money and to individual provider survival, not to the patient or to an improved healthcare system and in turn, societal benefit. This disconnect puts the larger goals in peril and, if we really care about them, we can either “trust” that someone out there is working on them, or start talking about it now. Your comments are welcomed…

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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