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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Technology Muddies Informed Consent

The concept of “consent” in healthcare is getting more complex and likely to create confusion not only to patients but also to clinicians and policy makers. Specifically, the term consent can be used in a variety of ways. First, it can refer to the process of determining whether or not a patient understands the clinical procedures and their inherent risks, and whether or not that patient has the capacity to understand and give their consent.

Secondly, EHRs and PHRs play a role in modifying this landscape. The HITECH provisions of the American Recovery and Reinvestment Act, passed February 17, 2009, include substantial financial incentives for the “meaningful use” of certified EHR systems. One of the qualifying requirements of meaningful use, by law, is the exchange of clinical data among physicians and hospitals using EHR systems.

All of these connected systems will eventually feed data across the country through the Nationwide Health Information Network (NHIN), which is still under development. Initially, the meaningful use connectivity requirement will be accomplished through many local and regional Health Information Exchanges (HIE), each of which will likely create very different rules for the exchange of clinical data along the network. The rules will vary by state and organization, since there are no standardized business or legal models for HIE structure.

In this scenario, patients will be asked for their consent to move their clinical data along these networks, as well as to use their information in a variety of ways ranging from mundane billing to clinical research. Consent for this purpose will not be standardized, nor will it be easy to comprehend, since some HIE models will allow patients to opt in while others require an opt out. To further obfuscate the situation, patients will be empowered to allow the movement of some of their data while restricting or withholding other data either under certain conditions or altogether.

We have an obligation to see that the value of information technology plays an appropriate and supportive role, and that we clearly articulate the difference between information consent and clinical consent.

We must make a distinction between information consent and clinical consent. Ethicists, clinicians and technologists make an effort to ensure that the use of information technology does not dehumanize the physician-patient relationship. We must recognize that it plays a role in expanding that relationship. We must take extra care to ensure that technology does not further complicate the process of making treatment decisions under difficult circumstances. If we do these things now, the transition to EHR can be a smoother one for all.

– Rod Piechowski

(See updated piece September 10, 2010)

Copyright © 2010, Rod Piechowski, Inc., Consulting

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“Meaningful” means nothing

I’ve had several conversations now in which someone has used the word “meaningful” and then, (while rolling their eyes) immediately tries to take it back, as if the word has been banned from our vocabulary. Of course, this only holds true if you work in healthcare, and are at all aware of how the American Recovery and Reinvestment Act (ARRA) and its sibling, the HITECH Act, have changed the way we think about information technology. Meaningful use of certified EHR systems is the new goal for all physicians and hospitals in order to avoid payment penalties. While there are many hospitals and physicians that have already implemented this technology over the past decade, those for whom the technology proved too expensive, complicated or otherwise elusive now look at the meaningful use requirements as the lowest bar over which they must jump in order to stay ahead of the payment reductions. Will the concept of meaningful use continue to evolve beyond the requirements that will be in place by 2015? It’s unfortunate Congress did not call this effort “basic use” or “initial use” of technology, for there are few ways to describe what is yet to come without resorting to “more meaningful” and “still more meaningful.”  Don’t get me wrong. I write this as an optimist, and believe that we will still see developments in health information technology that will make what we’re doing today seem like baby steps. Calling it “meaningful” today doesn’t really set that kind of tone for the future. We must accept that this will be a long, exciting journey, and find a new word to plug the hole in our vocabulary. There’s always “visionary.”

-Rod Piechowski

Copyright © 2010, Rod Piechowski, Inc., Consulting

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