Achieving meaningful use will require extensive training and time, which translates to big costs for providers. Approximately 62 percent of providers who already have or are planning to implement electronic health or medical records will spend more than 20 percent of their yearly IT spending on meaningful use-related projects this year, according to an InformationWeek survey. While hospitals are designating dollars for this undertaking, they will still face roadblocks along the way, such as physician resistance, aggressive timeframes and changed workflow. Here are eight problems hospitals may face in their efforts to achieve meaningful use.
1. Problem: Enrollment and attestation process for eligible providers is cumbersome for those with employed faculty.
Explanation: Hospitals with employed physician groups that are also part of a larger healthcare system need proxy access to manage the logistics of enrollment and attestation following the 90 days. The healthcare system has made the investment in an EHR and is ensuring, on the physician’s behalf, that meaningful use objectives are met as part of a broader implementation and maturing plan. Without proxy access, it is an unmanageable process to have 400+ physicians enroll individually and attest compared to a centralized process that is completed on their behalf.
Solution: CMS recognizes this gap, but has not committed to a firm timeframe as to when proxy access will be given. Meanwhile, organizations that are ready to enroll and begin the 90-day demonstration period are in a holding pattern, which translates into delays for receiving incentives.
2. Problem: Incentive payments for hospitals and eligible providers cover only 20-25 percent of the overall cost to implement an EHR and achieve meaningful use.
Explanation: The cost of implementing an EHR program greatly exceeds the amount of total reimbursement. The level of investment needed is on the same level and competing for limited capital dollars tied up in initiatives such as strategic facility decisions, purchase of biomedical equipment, ancillary clinical systems, etc.
Solution: Increased level of funding by the government and recognition that hospital-based physicians require ancillary systems that are not native in EHRs, yet are vital to the overall care of the patient. CMS incentives explicitly exclude hospital-based physicians and the focus is around the core EMR systems only. However, in order to build a complete record, investments beyond the core EMR are needed — adding significant costs. These may include a radiology information system, cardiovascular information system, laboratory and pathology system, and digital imaging system, such as picture archiving and communication systems.
3. Problem: Increased demand placed on providers detracts from patient care. Explanation: While tools such as macros, smart phrases and templates help with ease of electronic documentation, workflow is still slower than a paper-based chart. As a result, a lower volume of patients is seen and/or investments in physician extenders are needed.
Solution: Increased level of funding by the government. Electronics versus paper may slow down workflow, leaving physicians doing less clinical work and more administrative duties. This translates into one of two realities: a lower volume of patients seen, which means less revenue, or added cost to provide physicians with labor to assist them with administrative duties. While EHRs are beneficial for patients, they do add costs that directly impact physicians’ bottom line.
4. Problem: The majority of organizations are within the same relative progression phases of EHR implementation. There is a shortage of clinical analysts for whom organizations are competing to recruit, train and retain.
Explanation: A short-term, artificial inflation of labor costs is created due to demand outweighing supply. As organizations reach the end of the maturity model, a surplus of labor will exist, wages will diminish and jobs will be lost.
Solution: Progressive compensation and retention plans, along with employment agreements.
5. Problem: Implementation schedules for new enterprise applications are usually a lot longer than the timeline given for meaningful use.
Explanation: For organizations that began the process as a result of HITECH and meaningful use, the timeframe is extremely aggressive by comparison.
Solution: Given the much shorter timeframe for implementing certified EHR technology to meet meaningful use requirements, an institution would have to accelerate their implementation schedule by ramping up resources while having robust mechanisms in place to ensure quality of care and patient safety are not compromised.
6. Problem: Clinicians may resist the adoption of an EHR, especially if the hospital does not currently have any form of an EMR/EHR in place.
Explanation: Physicians, by virtue of the physician culture, are usually resistant to change and may be difficult to convince when it comes to switching from a paper-based workflow to an electronic workflow. Additionally, there could be significant variations in workflows between units in a hospital, prompting other clinicians’ resistance to change.
Solution: Careful, detail-oriented attention must be paid to existing workflows so as to not create cumbersome and inefficient workflows in the EHR. Adequate buy-in must be obtained from the clinical community by recruiting champions from various clinical professions. Standardization is key to successful implementation of an EMR/EHR and this expectation should be set and managed up front.
7. Problem: Maintaining an up-to-date shared problem list may prove to be problematic.
Explanation: One of the requirements of meaningful use is to maintain an up-to-date problem list so organizations can more effectively identify conditions among patient populations. By virtue of how EHRs function, problem lists are shared between all providers, but physicians tend to be territorial about their problem lists, which have been a standard component of medical records since the 1960s. Additionally, in the paper world, charts are usually not shared and each provider maintains his or her own problem list on a patient.
Solution: Set expectations early with physicians by creating a document that outlines problem list etiquette. Check with your EHR vendor and other institutions that have implemented your brand of EHR to see if they have any solutions to mitigate issues with the problem list.
8. Problem: EHRs have an abundance of data but do not have an abundance of readily available information. Meaningful use requires the reporting of hospital quality measures via use of certified EHR technology.
Explanation: You can essentially find any data you are looking for in an EHR system. The challenge is to extract the data into a meaningful format so providers can submit to meet meaningful use requirements. Also challenging is formatting quality measures and other information off of which stakeholders and end users can base decisions.
Solution: The time is now to ramp up medical informatics and business intelligence at your institution by investing in skilled resources and technology. Technology should be geared towards the ability to deliver meaningful reports and real-time dashboards.
Cooper University Hospital in Camden, N.J., is the clinical campus of the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School at Camden. It has more than 700 physicians in 75 specialties and offers a network of comprehensive services, including prevention and wellness, primary and specialty physician services, hospital care, ambulatory diagnostic and treatment services, and home health care within Southern New Jersey, Philadelphia and the entire Delaware Valley.
1. Problem: Enrollment and attestation process for eligible providers is cumbersome for those with employed faculty.
Explanation: Hospitals with employed physician groups that are also part of a larger healthcare system need proxy access to manage the logistics of enrollment and attestation following the 90 days. The healthcare system has made the investment in an EHR and is ensuring, on the physician’s behalf, that meaningful use objectives are met as part of a broader implementation and maturing plan. Without proxy access, it is an unmanageable process to have 400+ physicians enroll individually and attest compared to a centralized process that is completed on their behalf.
Solution: CMS recognizes this gap, but has not committed to a firm timeframe as to when proxy access will be given. Meanwhile, organizations that are ready to enroll and begin the 90-day demonstration period are in a holding pattern, which translates into delays for receiving incentives.
2. Problem: Incentive payments for hospitals and eligible providers cover only 20-25 percent of the overall cost to implement an EHR and achieve meaningful use.
Explanation: The cost of implementing an EHR program greatly exceeds the amount of total reimbursement. The level of investment needed is on the same level and competing for limited capital dollars tied up in initiatives such as strategic facility decisions, purchase of biomedical equipment, ancillary clinical systems, etc.
Solution: Increased level of funding by the government and recognition that hospital-based physicians require ancillary systems that are not native in EHRs, yet are vital to the overall care of the patient. CMS incentives explicitly exclude hospital-based physicians and the focus is around the core EMR systems only. However, in order to build a complete record, investments beyond the core EMR are needed — adding significant costs. These may include a radiology information system, cardiovascular information system, laboratory and pathology system, and digital imaging system, such as picture archiving and communication systems.
3. Problem: Increased demand placed on providers detracts from patient care. Explanation: While tools such as macros, smart phrases and templates help with ease of electronic documentation, workflow is still slower than a paper-based chart. As a result, a lower volume of patients is seen and/or investments in physician extenders are needed.
Solution: Increased level of funding by the government. Electronics versus paper may slow down workflow, leaving physicians doing less clinical work and more administrative duties. This translates into one of two realities: a lower volume of patients seen, which means less revenue, or added cost to provide physicians with labor to assist them with administrative duties. While EHRs are beneficial for patients, they do add costs that directly impact physicians’ bottom line.
4. Problem: The majority of organizations are within the same relative progression phases of EHR implementation. There is a shortage of clinical analysts for whom organizations are competing to recruit, train and retain.
Explanation: A short-term, artificial inflation of labor costs is created due to demand outweighing supply. As organizations reach the end of the maturity model, a surplus of labor will exist, wages will diminish and jobs will be lost.
Solution: Progressive compensation and retention plans, along with employment agreements.
5. Problem: Implementation schedules for new enterprise applications are usually a lot longer than the timeline given for meaningful use.
Explanation: For organizations that began the process as a result of HITECH and meaningful use, the timeframe is extremely aggressive by comparison.
Solution: Given the much shorter timeframe for implementing certified EHR technology to meet meaningful use requirements, an institution would have to accelerate their implementation schedule by ramping up resources while having robust mechanisms in place to ensure quality of care and patient safety are not compromised.
6. Problem: Clinicians may resist the adoption of an EHR, especially if the hospital does not currently have any form of an EMR/EHR in place.
Explanation: Physicians, by virtue of the physician culture, are usually resistant to change and may be difficult to convince when it comes to switching from a paper-based workflow to an electronic workflow. Additionally, there could be significant variations in workflows between units in a hospital, prompting other clinicians’ resistance to change.
Solution: Careful, detail-oriented attention must be paid to existing workflows so as to not create cumbersome and inefficient workflows in the EHR. Adequate buy-in must be obtained from the clinical community by recruiting champions from various clinical professions. Standardization is key to successful implementation of an EMR/EHR and this expectation should be set and managed up front.
7. Problem: Maintaining an up-to-date shared problem list may prove to be problematic.
Explanation: One of the requirements of meaningful use is to maintain an up-to-date problem list so organizations can more effectively identify conditions among patient populations. By virtue of how EHRs function, problem lists are shared between all providers, but physicians tend to be territorial about their problem lists, which have been a standard component of medical records since the 1960s. Additionally, in the paper world, charts are usually not shared and each provider maintains his or her own problem list on a patient.
Solution: Set expectations early with physicians by creating a document that outlines problem list etiquette. Check with your EHR vendor and other institutions that have implemented your brand of EHR to see if they have any solutions to mitigate issues with the problem list.
8. Problem: EHRs have an abundance of data but do not have an abundance of readily available information. Meaningful use requires the reporting of hospital quality measures via use of certified EHR technology.
Explanation: You can essentially find any data you are looking for in an EHR system. The challenge is to extract the data into a meaningful format so providers can submit to meet meaningful use requirements. Also challenging is formatting quality measures and other information off of which stakeholders and end users can base decisions.
Solution: The time is now to ramp up medical informatics and business intelligence at your institution by investing in skilled resources and technology. Technology should be geared towards the ability to deliver meaningful reports and real-time dashboards.
Cooper University Hospital in Camden, N.J., is the clinical campus of the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School at Camden. It has more than 700 physicians in 75 specialties and offers a network of comprehensive services, including prevention and wellness, primary and specialty physician services, hospital care, ambulatory diagnostic and treatment services, and home health care within Southern New Jersey, Philadelphia and the entire Delaware Valley.