CIOs explore how meaningful use proposals will impact providers

The Center for Medicare & Medicaid Services' (CMS) proposed rules for incentive payments to eligible healthcare professionals and hospitals participating in Medicare and Medicaid programs that adopt and meaningfully use certified EHR technology is the result of unprecedented collaboration among leaders from all areas of healthcare. However, the 556-page document, released Dec. 30, 2009, is raising questions and concerns in the healthcare community--some of which were raised by two CIOs in a CMIO interview.

Recently, CMIO asked two members of the College of Healthcare Information Management Executives (CHIME) for their thoughts about the proposals. We spoke with Indranil Ganguly, CHICO, FHIMSS, vice president and CIO of CentraState Healthcare System, in Freehold, N.J.; and Russell P. Branzell, FCHIME, CIO and vice president, Poudre Valley Health System, in Fort Collins, Colo.

What this will mean to hospitals and, specifically, health IT administrators, if it gets enacted?

Branzell: Hospitals that have already been doing this for years have had a plan on this. I‘m not overly concerned about it in the preliminary rules, I think it’s a good start for the whole country...There’s not a great concern with being compliant because these rules if anything, [don’t set] a high bar for meeting for organizations that have had a plan for EHR systems, computerized provider order entry (CPOE) and evidence-based medicine. For all those things that are necessary, this fits right in with it. It’s a great opportunity to get some government funding toward what was already in place, if not some funding to take healthcare technologies to the next level.

I am concerned, not necessarily for health systems, but for the smaller hospitals and the critical access facilities, those types that are nowhere near down that road or had plans for that. It’s going to be very difficult for them to do it alone, or to even be able to get the resources necessary to implement these technologies. There also are some concerns on that part, for those types of facilities or small individual physician offices that are going to look to their health system partners that are out there to help them as well.

Ganguly: As I read through the proposal, I struggled to understand how I would even measure some of things they are asking us to measure in order to demonstrate compliance. We’re looking at CPOE, and we’re disappointed to see that’s being narrowly focused on the inpatient setting. [But] there are probably an equal number of colleagues who are happy about that because if you included ED or those kind of venues [in your CPOE compliance measurement], your denominator increases dramatically. In my community hospital, we are doing CPOE in the ED, and it would be a great benefit.

What are the odds of it getting enacted?

Ganguly: The likelihood of these measures getting enacted is high, though there will hopefully be some modifications.

Branzell: I don't think we have a choice about getting them enacted; the law will be enforced. Now, will they be operationalized in facilities out there? That's the key question. For most medium to large health systems and physician groups, I have extremely high confidence that this will happen. But in the small physician offices, the smaller community or critical access facilities, I think this going to be a challenge for them.

And there's still a portion of people that are excluded: Non-Medicare/Medicaid participating facilities or physician offices. An example would be one of our larger physician offices in the community. They're not owned or employed by the health system, but their clinic really is not eligible for any of this at all. Because of their [patient] mix, they take no Medicare and almost no Medicaid, because we have safety net providers in town, so there's nothing for that physician office--and it's 30-plus doctors, not using an EHR.

Fortunately, we've been working with them and others where we think we can provide some community assets and health system assets to help them. But there's got to be equivalent practices like that all over the county. How do you help them? Hopefully, you help them through the regional health extension centers, through other grant programs that were intended for those that were excluded. But there's going to be quite a few that won't, right out of the gate, and therefore will be targeted for those that should be compliant. However, I have high confidence that it'll happen.

Is there anything in the proposal that surprised you?

Branzell: The thing that surprised me the most was that when these first 2011 requirements came out, there were some pretty high thresholds, like complete order entry for e-prescribing for an outpatient physician office. Now it's been lowered to 80 percent. I think that's a surprise that some of these requirements were put at a lower level. I understand their rationale and I don't necessarily disagree with the rationale, there needs to be some room for error or for places that can't get to that right away. That was the one surprise to me.

The requirements were very consistent with what were present previously. I have a lot of respect for the people I know on the standards committee. Some of the best and the brightest in the country are there, and with  representation from CIOs, nurses, doctors. We had the right representation on those standards committees and those areas, then this production of these requirements in turn really did represent what we need as a country to move forward.

On the negative side, there is still a significant amount of detail to be defined and put into practice at the local state, regional and national level. Many of the metrics and measures have never been completed and monitored in an electronic environment. There is a significant amount of work ahead with limited and stretched resources for almost all health systems and provider offices.

Ganguly: I’m not surprised but I’m somewhat disappointed and concerned. These people are doing a tremendous amount of work to try and put together something that is unheard of, really. However, as a CIO or a community hospital, I am concerned about how we would comply with these—and we’re a fairly aggressive user of IT.

The other thing we’re struggling with is the all-or-nothing nature of it. There are 23 compliance points, and if you don’t comply with all 23, you don’t qualify at all. As a group, we are trying to perhaps suggest a weighting or ranking system [with which] at least we could pro-rate compliance and qualify for some of the funds based on the level of effort put forward.