Under the American Recovery and Reinvestment Act of 2009, healthcare providers are able to qualify for incentive payments upon adopting and demonstrating meaningful use of healthcare information technology, particularly electronic health records. Starting in 2011, these incentive payments will be distributed to hospital applicants that are able to successfully meet 19 requirements as outlined by the first stage of the meaningful use final rule. Here, Stephen Stewart, FCHIME, CIO of Henry County Health Center in Mount Pleasant, Iowa, and Bill Spooner, FCHIME, senior vice president and CIO of Sharp HealthCare in San Diego, share 11 ways hospitals can cash in the maximum amount of incentive payments.
1. Figure out what your maximum reimbursement is based on formulas in the regulation. Hospitals, depending on their eligibility under the Medicare fee-for-service, Medicare Advantage and Medicaid programs, should calculate their maximum amount of incentive payment based on the formulas outlined in the final rule and set that maximum amount as a goal. Hospitals should be particularly wary when calculating maximum reimbursement, as incentive payments are not standard across the board. For example, although fee-for-service hospitals are eligible for a base amount of $2 million with added "discharge related amounts," critical access hospitals, such as HCHC, follow a different calculation.
"It all starts with having your clinical leaders and IT leaders sit down with the financial leaders and figure out, based on these formulas, what your hospital qualifies for, what it has to do in order to reach that maximum reimbursement and how to continue qualifying for payments in 2013 and 2015," Mr. Stewart says. "Hospitals also have to remember they are subject to Medicare payment reductions starting in 2015 if they aren't demonstrating meaningful use in the future."
2. Understand the core 14 objectives and the five objectives your hospital chooses from a menu of 10 needed to meet stage 1. Ultimately, hospitals will have to meet all 24 requirements mandated by the meaningful use final rule, but stage 1 only requires hospitals meet 14 core requirements and five requirements that they are able to choose from a menu of 10 total requirements. In order to meet these objectives, as well as 15 clinical quality measures, 80 percent of patients must have records in the certified EMR technology. A full list of stage 1 objectives and measures can be found on the CMS website (pdf).
"When hospitals are looking at the menu list of objectives, they have to carefully scan and select the low-hanging fruit first because you don't have to do them all in stage 1," Mr. Stewart says. "Eventually hospitals will have to meet all 24 of the objectives, but for stage 1 if there is one or two items on the menu list that a hospital finds challenging, it shouldn't select those. Incentive payments are an all or nothing deal, so make sure you can address the core 14 and the easiest five menu items. "
3. Implement EMRs in a way that maximizes efficiency. In order to obtain the maximum incentive funds, hospitals must first begin with re-working work flows so that physicians and other healthcare providers are able to use the EMR system efficiently with minimum impact on productivity. At HCHC, simple changes in work flows, such as asking demographic questions during registration as opposed to during intake with the physician, helps the patient move through the care process faster. This way, the physician is able to save time and maximize productivity, which encourages him or her to continue using the EMR in a meaningful manner.
"Questions to patients, like what their preferred language is, traditionally were asked at intake by clinicians, but we realized that if those questions are asked at registration, all the clinician has to do is confirm the patient's answers," Mr. Stewart says. "Our strategy is to work and talk with the physicians, get input from them and build a system that is most efficient for their use."
4. Mix learning and adoption methods. In the same vein as maximizing efficient work flows, hospitals must also make sure the appropriate training is being offered to physicians and staff. Diligent training across the entire hospital is important, and leaders can use a variety of approaches tailored to the learning styles of its physicians and staff. Mr. Spooner says classroom-based or computerized training are the two main options at Sharp Healthcare for training staff on how to use EMRs.
"We've used the traditional classroom training and computerized training through Adobe, which uses scripted training to talk users through how to use our EMR and reinforce what they learned in the classroom," he says. "Organizations, though, are starting to look at computer-based training as a substitute for the classroom because it gives the learner more flexibility and is less expensive since it doesn't require a human trainer."
5. Form a steering committee. At HCHC, a steering committee comprised of representatives from all clinical and administrative departments ensures all hospital representatives collectively come together to solve issues related to efficient and meaningful use of its EMR system. On a monthly basis, these leaders discuss a wide range of matter, spanning from what changes in work flow need to be made, what new technologies need to be reviewed or acquired and so on.
"The key here is really communication, and having all the constituencies of our hospital represented in this steering committee is really important because all this has a bearing on clinical outcomes, finance, the billing department and so on," Mr. Stewart says. "Hospitals will also want to make sure they involve the clinical staff because implementing a system is one thing; getting clinicians to use it is another. Ultimately, if you don't use it, you won't get the money."
6. Elect an IT medical director and health informatics nurse. In addition to having a steering committee to quarterback meaningful use issues, hospitals will also benefit immensely from electing an IT medical director and health informatics nurse. The IT medical director at HCHC, who is a permanent member of the steering committee, is responsible for acting as a liaison between hospital staff, IT technicians, medical practices and the steering committee. As problems related to meaningful use of HCHC's EMR system arise, clinicians voice their concerns to the director who then relays those concerns to the steering committee. "If a clinician has a problem using the EMR system, then everyone goes back to the drawing board because not everything is going to work right the first time," Mr. Stewart says. "This role helps us to quickly address those issues to mitigate the impact of problems as they occur."
The health informatics nurse at HCHC, who also serves as a liaison to medical staff, is also charged with spearheading the actual implementation and execution of its EMR system. "The health informatics nurse is really a nurse by training, but she is also highly proficient in technology," Mr. Stewart adds. "She actually develops flow sheets and electronic forms, sets up applications and tests them and so on."
7. Meet with your vendor regularly to ensure your EMR is working optimally. To maximize efficiency and meaningful use, hospital leaders should strive to meet with their contracted vendor partners as often as possible to communicate and rectify IT problems. Mr. Stewart says he meets with representatives of the two vendors HCHC works with at least on a quarterly basis but usually meets with them in the interim.
"You want to be careful in choosing the right EMR vendor partner and foster a true partnership with them," he says. "I meet with them constantly and ask them what the roadmap to the future is so they can serve us well going forward, especially as these rules start to come out for stage 2 and stage 3."
8. Consider a vendor's implementation recommendations. Mr. Spooner says hospitals should seriously consider implementation approaches, or structured implementation methodologies, that are being promoted by EMR vendors. Vendors may promote implementation methodology to a hospital and communicate their best practices in a semi-standardized configuration. Mr. Spooner says the advantage in adopting a vendor's recommendations for implementation is that the companies usually compile best practices gleaned from previous successful deployments, allowing your hospital the opportunity to deploy a system more quickly and without the complication of configuring a system from the ground up.
"The previous method for hospitals was working with a vendor with a clean slate and communicating to the company what the hospital wants the system to look like and do, and often trying to configure a system and all its applications like that takes longer and doesn't necessarily make the best use of a system," he says. "With our first hospital, we chose to adopt the vendor's methodology and deployed in 15 months a system that would have taken us three years to deploy otherwise."
9. Reach out to established organizations. Hospitals should reach out to organizations specializing in healthcare IT or who are keenly aware of the legislation related to meaningful use of EMRs to help better understanding the regulations and criteria for meaningful use. With still so much uncertainty surrounding future criteria and regulations, moving forward with EMR implementation can feel like a risky venture, but Mr. Spooner says that while meaningful use final rules and regulations may seem like a moving target, it is still an achievable one.
"In terms of understanding the rules for meaningful use, there are number of organizations that are good at communicating through email, webinars and other mediums clarification on what those rules are," he says. 'There is an active effort by CHIME and HIMSS to offer educational opportunities for hospitals. There is a lot of reading and listening, but there's plenty of information available to hospitals."
10. Strategize your approach to meaningful use going forward. While hospitals are still rushing to meet stage 1 requirements, hospitals will benefit from looking ahead to 2013 and 2015 as well. The Office of the National Coordinator will likely roll out increasingly complex requirements for stage 2 and stage 3 of meaningful use. Although rules and regulations regarding future stages of meaningful use are only speculation at this point, Mr. Spooner says some predictions can still be made to help prepare for those future criteria.
"One area that is less mature is the area of information exchange, and that is still in flux in terms of what the expectations coming out of CMS and ONC will be," he says. "Although there is still a lot of debate going on in terms of information exchanges, it doesn't seem the HIE requirement will go away, so I advise organizations to get engaged in the community to find effective HIE solutions so that by fiscal year 2014, they are already on the road to operating one."
Mr. Spooner adds that hospitals should prepare for the changes expected to come out of stage 2 and stage 3 for quality indicators of meaningful use. "Based on all the reading that I do, it appears that while specific indicators may vary or come and go, there are a few things that are pretty solid in terms of expectations for stage 2 and stage 3, and one is quality indicators," he says. "Hospitals are going to need to possess an automated way of collecting data on quality and show by stage 3 how they are improving clinical outcomes as a result of capturing that data. Looking ahead can really help a hospital maximize its meaningful use."
Mr. Stewart also predicts that while stage 1 requires eligible fee-for-service or critical care hospitals demonstrate more than 30 percent of unique patients have at least one medication entered using CPOE, that percentage could possibly increase to 60 or 70 percent.
11. Wait another year to apply, if need be. If your healthcare organization isn't ready to meet stage 1 requirements for meaningful use, Mr. Spooner suggests waiting another year before applying to make sure all concerns, technical issues and other obstacles are addressed. "One thing organizations should consider, depending on where they are in adoption cycle, is to maybe wait a year. One risk with going ahead and applying is that once you begin the application for fulfilling stage 1 requirements, there is an expectation that you also fulfill stage 2 requirements," he says. "It might be wise to wait a year to apply for stage 1 because that gives you an extra year to make stage 2."
Tackle the basics
1. Figure out what your maximum reimbursement is based on formulas in the regulation. Hospitals, depending on their eligibility under the Medicare fee-for-service, Medicare Advantage and Medicaid programs, should calculate their maximum amount of incentive payment based on the formulas outlined in the final rule and set that maximum amount as a goal. Hospitals should be particularly wary when calculating maximum reimbursement, as incentive payments are not standard across the board. For example, although fee-for-service hospitals are eligible for a base amount of $2 million with added "discharge related amounts," critical access hospitals, such as HCHC, follow a different calculation.
"It all starts with having your clinical leaders and IT leaders sit down with the financial leaders and figure out, based on these formulas, what your hospital qualifies for, what it has to do in order to reach that maximum reimbursement and how to continue qualifying for payments in 2013 and 2015," Mr. Stewart says. "Hospitals also have to remember they are subject to Medicare payment reductions starting in 2015 if they aren't demonstrating meaningful use in the future."
2. Understand the core 14 objectives and the five objectives your hospital chooses from a menu of 10 needed to meet stage 1. Ultimately, hospitals will have to meet all 24 requirements mandated by the meaningful use final rule, but stage 1 only requires hospitals meet 14 core requirements and five requirements that they are able to choose from a menu of 10 total requirements. In order to meet these objectives, as well as 15 clinical quality measures, 80 percent of patients must have records in the certified EMR technology. A full list of stage 1 objectives and measures can be found on the CMS website (pdf).
"When hospitals are looking at the menu list of objectives, they have to carefully scan and select the low-hanging fruit first because you don't have to do them all in stage 1," Mr. Stewart says. "Eventually hospitals will have to meet all 24 of the objectives, but for stage 1 if there is one or two items on the menu list that a hospital finds challenging, it shouldn't select those. Incentive payments are an all or nothing deal, so make sure you can address the core 14 and the easiest five menu items. "
Encourage meaningful use among users
3. Implement EMRs in a way that maximizes efficiency. In order to obtain the maximum incentive funds, hospitals must first begin with re-working work flows so that physicians and other healthcare providers are able to use the EMR system efficiently with minimum impact on productivity. At HCHC, simple changes in work flows, such as asking demographic questions during registration as opposed to during intake with the physician, helps the patient move through the care process faster. This way, the physician is able to save time and maximize productivity, which encourages him or her to continue using the EMR in a meaningful manner.
"Questions to patients, like what their preferred language is, traditionally were asked at intake by clinicians, but we realized that if those questions are asked at registration, all the clinician has to do is confirm the patient's answers," Mr. Stewart says. "Our strategy is to work and talk with the physicians, get input from them and build a system that is most efficient for their use."
4. Mix learning and adoption methods. In the same vein as maximizing efficient work flows, hospitals must also make sure the appropriate training is being offered to physicians and staff. Diligent training across the entire hospital is important, and leaders can use a variety of approaches tailored to the learning styles of its physicians and staff. Mr. Spooner says classroom-based or computerized training are the two main options at Sharp Healthcare for training staff on how to use EMRs.
"We've used the traditional classroom training and computerized training through Adobe, which uses scripted training to talk users through how to use our EMR and reinforce what they learned in the classroom," he says. "Organizations, though, are starting to look at computer-based training as a substitute for the classroom because it gives the learner more flexibility and is less expensive since it doesn't require a human trainer."
Establish IT-focused staff
5. Form a steering committee. At HCHC, a steering committee comprised of representatives from all clinical and administrative departments ensures all hospital representatives collectively come together to solve issues related to efficient and meaningful use of its EMR system. On a monthly basis, these leaders discuss a wide range of matter, spanning from what changes in work flow need to be made, what new technologies need to be reviewed or acquired and so on.
"The key here is really communication, and having all the constituencies of our hospital represented in this steering committee is really important because all this has a bearing on clinical outcomes, finance, the billing department and so on," Mr. Stewart says. "Hospitals will also want to make sure they involve the clinical staff because implementing a system is one thing; getting clinicians to use it is another. Ultimately, if you don't use it, you won't get the money."
6. Elect an IT medical director and health informatics nurse. In addition to having a steering committee to quarterback meaningful use issues, hospitals will also benefit immensely from electing an IT medical director and health informatics nurse. The IT medical director at HCHC, who is a permanent member of the steering committee, is responsible for acting as a liaison between hospital staff, IT technicians, medical practices and the steering committee. As problems related to meaningful use of HCHC's EMR system arise, clinicians voice their concerns to the director who then relays those concerns to the steering committee. "If a clinician has a problem using the EMR system, then everyone goes back to the drawing board because not everything is going to work right the first time," Mr. Stewart says. "This role helps us to quickly address those issues to mitigate the impact of problems as they occur."
The health informatics nurse at HCHC, who also serves as a liaison to medical staff, is also charged with spearheading the actual implementation and execution of its EMR system. "The health informatics nurse is really a nurse by training, but she is also highly proficient in technology," Mr. Stewart adds. "She actually develops flow sheets and electronic forms, sets up applications and tests them and so on."
Work closely with outside resources
7. Meet with your vendor regularly to ensure your EMR is working optimally. To maximize efficiency and meaningful use, hospital leaders should strive to meet with their contracted vendor partners as often as possible to communicate and rectify IT problems. Mr. Stewart says he meets with representatives of the two vendors HCHC works with at least on a quarterly basis but usually meets with them in the interim.
"You want to be careful in choosing the right EMR vendor partner and foster a true partnership with them," he says. "I meet with them constantly and ask them what the roadmap to the future is so they can serve us well going forward, especially as these rules start to come out for stage 2 and stage 3."
8. Consider a vendor's implementation recommendations. Mr. Spooner says hospitals should seriously consider implementation approaches, or structured implementation methodologies, that are being promoted by EMR vendors. Vendors may promote implementation methodology to a hospital and communicate their best practices in a semi-standardized configuration. Mr. Spooner says the advantage in adopting a vendor's recommendations for implementation is that the companies usually compile best practices gleaned from previous successful deployments, allowing your hospital the opportunity to deploy a system more quickly and without the complication of configuring a system from the ground up.
"The previous method for hospitals was working with a vendor with a clean slate and communicating to the company what the hospital wants the system to look like and do, and often trying to configure a system and all its applications like that takes longer and doesn't necessarily make the best use of a system," he says. "With our first hospital, we chose to adopt the vendor's methodology and deployed in 15 months a system that would have taken us three years to deploy otherwise."
9. Reach out to established organizations. Hospitals should reach out to organizations specializing in healthcare IT or who are keenly aware of the legislation related to meaningful use of EMRs to help better understanding the regulations and criteria for meaningful use. With still so much uncertainty surrounding future criteria and regulations, moving forward with EMR implementation can feel like a risky venture, but Mr. Spooner says that while meaningful use final rules and regulations may seem like a moving target, it is still an achievable one.
"In terms of understanding the rules for meaningful use, there are number of organizations that are good at communicating through email, webinars and other mediums clarification on what those rules are," he says. 'There is an active effort by CHIME and HIMSS to offer educational opportunities for hospitals. There is a lot of reading and listening, but there's plenty of information available to hospitals."
Look toward the future
10. Strategize your approach to meaningful use going forward. While hospitals are still rushing to meet stage 1 requirements, hospitals will benefit from looking ahead to 2013 and 2015 as well. The Office of the National Coordinator will likely roll out increasingly complex requirements for stage 2 and stage 3 of meaningful use. Although rules and regulations regarding future stages of meaningful use are only speculation at this point, Mr. Spooner says some predictions can still be made to help prepare for those future criteria.
"One area that is less mature is the area of information exchange, and that is still in flux in terms of what the expectations coming out of CMS and ONC will be," he says. "Although there is still a lot of debate going on in terms of information exchanges, it doesn't seem the HIE requirement will go away, so I advise organizations to get engaged in the community to find effective HIE solutions so that by fiscal year 2014, they are already on the road to operating one."
Mr. Spooner adds that hospitals should prepare for the changes expected to come out of stage 2 and stage 3 for quality indicators of meaningful use. "Based on all the reading that I do, it appears that while specific indicators may vary or come and go, there are a few things that are pretty solid in terms of expectations for stage 2 and stage 3, and one is quality indicators," he says. "Hospitals are going to need to possess an automated way of collecting data on quality and show by stage 3 how they are improving clinical outcomes as a result of capturing that data. Looking ahead can really help a hospital maximize its meaningful use."
Mr. Stewart also predicts that while stage 1 requires eligible fee-for-service or critical care hospitals demonstrate more than 30 percent of unique patients have at least one medication entered using CPOE, that percentage could possibly increase to 60 or 70 percent.
11. Wait another year to apply, if need be. If your healthcare organization isn't ready to meet stage 1 requirements for meaningful use, Mr. Spooner suggests waiting another year before applying to make sure all concerns, technical issues and other obstacles are addressed. "One thing organizations should consider, depending on where they are in adoption cycle, is to maybe wait a year. One risk with going ahead and applying is that once you begin the application for fulfilling stage 1 requirements, there is an expectation that you also fulfill stage 2 requirements," he says. "It might be wise to wait a year to apply for stage 1 because that gives you an extra year to make stage 2."