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How to Use Meaningful Use Measures to Improve Internal Processes By Shubho Chatterjee, PhD, PE
The final ruling on Meaningful Use was released by the Centers for Medicare and Medicaid Services in July of this year after a year of comment period and revisions. According to the final ruling, to be eligible for incentive payments, Eligible Professionals (EPs) are required to submit to the CMS, starting October 2011, 20 objective measures for 15 core objectives and an additional five from a menu of 10. For hospitals and Critical Access Hospitals (CAHs) the corresponding measures are from 14 core objectives and five from a menu of 10.
There are various efforts, dialogues, and debates underway regarding the ability of EPs, hospitals, and CAHs to meet the reporting requirements, whether the cost justifies the incentives, and the sheer human and technical capacity needed. I will not further add to the discussions but will rather focus on how the MU criteria can be used to further improve care delivery process, make it more efficient, and positively impact the operating margin. After all, a measure is related to the output of a process, and while a measure can be met, it can also be used to hone into the process and sub-processes for improvement.
Let us consider some of these Stage 1 measures and how the underlying processes supporting the reporting of the measure can be identified and improved to further improve the measure, the care delivery, and the operating margin.
Stage 1 Measure More than 30% of unique patients with at least one medication in their list seen by the EP or admitted to eligible hospital’s or CAH’s ED have at least one medication order entered using CPOE.
Implication Let’s assume that the provider meets the 30% threshold for the reporting period. A logical follow-through is to examine why the remainder are not CPOE and what were some barriers overcome to reach this threshold. Is it because for the remainder unique patient population, data entry is manual because other providing locations are not CPOE enabled, CPOE is available but under-utilized, or are there manual data entry requirements into and between various systems and consolidate the data to one final measure?
Each of these barriers point to a different challenge. The first is system unavailability (a business decision). The second is a change management (a people challenge). The third is a technical and process automation challenge requiring an interface or other electronic inputs, such as document management and integration.
Stage 2 and Stage 3 measures will increase the threshold. Thus the underlying process or system gaps should be identified not only to meet later Stage measures, but to improve process efficiencies as well.
Stage 1 Measure More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology.
Implication Assuming the 40% threshold is met, what is necessary to increase the measure? Is it because of volume of data entry from single or multiple locations, or system not fully utilized, or could it be because the receiving pharmacy or is unable to manage additional increases to their receiving capacity from their customers? Again, the barriers are similar to the above and need to be analyzed and overcome.
Stage 1 Measure More than 10% of all unique patients seen by the EP are provided timely (available to the patient within four business days of being updated in the certified EHR technology) electronic access to health information subject to EP’s discretion to withhold certain information.
Implication This requirement has procedural, technical, and operational implications. The procedural requirements are in providing HIPAA compliant health information, while the technical requirements are in the mode of providing the information. For example, will a secure patient portal be created, will the information be provided in memory sticks or other portable devices, and if so, what is the encryption or data protection policy?
Note that, depending on the technical solution selected, there are supply chain and purchasing requirements as well, to maintain and increase the measure threshold.
Summary While the MU provides financial incentives for healthcare organizations, it ends in 2015. It is important for healthcare organizations to use this opportunity, not only to prepare, apply for, and receive the incentives, but to examine their organizations deeply from People, Process, and Systems perspective to utilize and enhance the measures.
Only when these three supports are robust and reliable will the Meaningful Use be truly meaningful to the healthcare system, where the improvement of quality of care is the most important objective and operational improvements and business growth will likely follow.
Bringing Medical Terminology Management into the 21st Century — Just in Time for ICD-10 By George Schwend
ICD-10 promises to improve patient safety, the granularity of diagnosis codes, and diagnostic and treatment workflows as well as billing processes. Sounds like a dream, right? But close to three years from the mandated switch on October 1, 2013, most hospitals and health systems are still thinking of it as a nightmare, dreading the massive amount of time, effort, and money the transition will require.
What many fail to grasp is that ICD-10 is just one step on an endless road. There are already dozens of code sets that will probably eventually need to be integrated with each other — from SNOMED-CT and LOINC to RxNorm to local terminologies and proprietary knowledge bases — and all of them are constantly evolving. Look down the road and you can see ICD-11, already in alpha phase in Europe.
Instead of tackling each new iteration as if they were setting off on a major road trip through uncharted territory, providers, payers, and IT vendors need to ditch the proverbial roadmaps and get themselves a GPS unit. That way, they can simply enter each new destination as it comes along and travel there automatically.
And automation is what true semantic interoperability requires. Our metaphorical GPS could either be embedded in proprietary HIT software or plugged into a hospital’s or payer’s information system and triggered by specific events such as an update or the need to create new maps. It would allow users to automatically:
update, map, search, browse, localize, and extend content
incorporate and map local content to standards
update standard terminologies and local content
generate easy-to-use content sets to meet the needs of patients, physicians, and customer support professionals
reference the latest terminology in all IT applications
codify free text
set the stage for converting data into actionable intelligence
Happily, software that fits the bill is already available, in use today at more than 4,000 sites on five continents. It provides mapping and terminology for leading HIT vendors, for health ministries like the UK National Health Service, and for standards organizations such as the IHTSDO, owner of SNOMED-CT., allowing them to not only implement new codes but synchronize codes throughout an enterprise, be it a physician practice or a country.
If you are still having nightmares about ICD-10, this your wake-up call. The ability to merge and manage diverse content from multiple sources — including free text from physician dictation — is what will turn ICD-10 from a frantic, one-off billing upgrade to one in a series of opportunities seized: to move clinical diagnosis to a new level, for example, to optimize EMRs, to meet meaningful use requirements, to satisfy quality initiatives such as the Physician Quality Reporting Initiative and to support robust analytics and reporting.
HIE Market, A Shot in the Arm By Tim Remke The HIE market finally got a shot in the arm with the passage of the federal stimulus. This and other tailwinds sent hundreds of millions of dollars over the next few years toward the HIE market. From this point on, the HIE market gets muddled. Questions such as who is marketing their solutions to which markets, what deployed-use cases are functional or even operate at a high level, and what differences exist between multi-stakeholder, state, and private HIEs are mixed among many other multi-faceted questions.
The definition of a health information exchange has diluted the significance of surveys and results, particularly when they seek to understand what types of data are exchanged, the number of HIEs in the market and their respective operational capacity, and technological and governance structures. Simply, too many results are ‘self-reported’ and produce statistically insignificant, inaccurate, or misleading data points.
Of particular concern, several market surveys and reports related to the HIE market have commingled data by combining statistics from provider organizations that use solutions developed for basic hospital portals — a far cry from a broader HIE platform. Finally, HIEs may be private, multi-stakeholder, or statewide entities. In addition, payer system and public health play a role of delineation. The idea of ‘community HIE’ is limiting, and does not tier appropriately the HIE market.
With this perspective and understanding, we assess a few basic aspects of the current state of the HIE market.
Target Markets A tremendous amount of friction exists over what specific HIE markets are accelerating at a pace greater than others, and which companies target each market. For example, a few vendors are persistent in their belief that the private HIE market is really the first ‘go-to-market strategy’ place. They look for localized geographies or a few hospitals to install an HIE platform as an overlay solution to act as a ‘buffer’ to a larger regional or statewide exchange.
Within the same HIE market, but more counter to this strategy, are the vendors who seek larger contracts from statewide or vast regional, multi-stakeholder exchanges. Two different approaches that produce some small and other more significant variation in solution focus and offerings. However, the data indicates a consistency that is expected. A
ll vendors will market to almost any market. However, slicing through the data, we see vendors that are targeted. All focus on hospital to hospital environments. Approximately 85 percent focus on providing an acute to ambulatory framework, also; and less than 40 percent offer a platform that readily integrates physician groups.
In addition, and somewhat paradoxically, many solutions are simply not designed to operate as platforms for vast geographic or state exchanges. Therefore, for the multi-stakeholder market, HIE solutions are discriminating. Contrast arises between target markets and the ability of the solution to match the specific market. Unlike other segments, HIEs seem as equally conflicting in details as they are syncopated — characteristics of a nascent market (relative to the past few years).
Critical Minimal Requirements In recent months, we have seen a number of RFPs that contain a significant number of demands. However, they mask a serious issue in the HIE market. The reality is most HIEs are ill-equipped to take on sophisticated and complex solutions, use-cases, and technical architectures they greatly desire. Furthermore, over 65 percent stated the minimal exchange of data from information systems were posing “mission critical problems” with their respective exchange, and will succumb to “serious delays”. The table below looks at minimum versus preferred requirements for an exchange structure.
Conclusion Finally, the HIE market is dynamic and has hit full stride. Companies that have weathered the storm seek potential exits (i.e. merger and acquisitions) while others are ramping their solution for the future. The market will likely extend an abnormal growth rate for the next one to two years.
However, many unanswered questions will remain. Business models, measured quality improvements, and funding, among other items persist into the future as open question marks. For example, initial stimulus funds will jump start statewide HIEs. However, after these funds have been depleted, real concerns about long-term viability and funding sources will endure.
From Gregarious: “Re: HCA. They are doing competitive pilots of Meditech 6.0 vs. Cerner, possibly as a move toward displacing the long-term HCA / Meditech relationship.” Verified. HCA will run a Cerner pilot in at least one hospital sometime next year. Meditech 6.0 is a big step from HCA’s Magic (pretty much starting over), so it makes sense to test the waters. The wild card could be how the hosting models compare. Several HCA hospitals have reached EMRAM Stage 6 on Magic, which ironically makes it harder for HCA to switch since you’d need heavy clinical usage from Day One to avoid moving backward. Any change (even to 6.0) will be painful.
From BeCarefulWhatYouWishFor: “Re: Epic. They are about to pick up another large academic facility in Nebraska. You can only imagine who is going to have the LastWord now.” Unverified, but thanks for the excellent punmanship in any case. As a couple of readers pointed out, it will be interesting to see if Epic can scale its model up to cover all these big implementations going on at once. A CIO reader who knows both systems says Cerner requires clients to take ownership of the design and use outside consultants, while Epic offers a more turnkey implementation at a higher price. It’s also interesting that Epic doesn’t offer hosting and Cerner is runnin hard with that offering, so that’s a key differentiator to some prospects.
From SnagMonkey: “Re: Epic. Not officially announced, but all Providence hospitals and hospitals in Oregon will convert to Epic.” Unverified.
From You’ll Know Who: “Re: Epic. Not only is Epic replacing Eclipsys and Cerner at sites, they are likely removing 30+ year old financial systems from McKesson, such as HealthQuest or the old Ibax product. That again highlights the lack of success with the ‘new’ Horizon ERM. It would be interesting to hear which products the CIOs looked at.” My ears are open if anyone wants to share.
From Ragnar Danneskjold: “Re: your comments about Cerner and corporate bureaucracy. Man, can you turn a phrase! I’m going to have that framed and put on my office wall (and then wonder why my career is not going anywhere ). Been loving your work for many years now. I don’t know how you do it, but keep on doing it.” Thanks.
From Cheers Across Atlanta: “Re: Eclipsys. Jay Deady announced today at the Eclipsys sales meeting that he will be leaving concurrent with the Allscripts acquisition.” Unverified.
From Reddy Kilowatt: “Re: PM/EMR in Asia. I’m looking for information (Web sites, articles, databases, etc.) on penetration in the smaller private practice market.” I have readers there, so if you know some sources, let me know.
From Anonymous: “Re: Merge Healthcare’s ortho imaging products. I’m surprised you didn’t catch wind of this.” I did, earlier this month when a reader tipped me off that Stryker was selling its imaging division (i.e., ortho products) to Merge.
From Lori S: “Re: AirStrip Technologies. They will announce that their cardio and critical care apps have received FDA approval, setting the bar high for other vendors.” Verified. The news just came across the wire Tuesday evening. AirStrip users can monitor patients in real time from their iPhone, iPad, and other mobile devices. That sound you heard was change jingling in the deep pockets of GE, Philips, etc. as they suddenly think AirStrip Technologies looks like something they’d like to get their hands on. I interviewed co-founder Cameron Powell, MD in February.
SRS will offer customers its hybrid EMR bundled with practice management and scheduling systems from Ingenix, calling it SRS CareTracker PM powered by Ingenix. SRS will also offer its EMR customers a migration path to the Ingenix CareTracker EHR. That’s interesting — Ingenix has been promoting CareTracker much more heavily recently, plus rumors suggest that the company won’t stop its HIT-related acquisitions with Picis.
I’m a sucker for hospital music videos, so here’s one from Lake Pointe Medical Center in Rowlett, TX, a top-rated Tenet facility celebrating its 5-Star Patient Satisfaction Rating for the full year of 2009.
Marshfield Clinical lists its CIO job. An advanced degree is not required.
Fisher-Titus Medical Center (OH) is happy with its Cerner implementation, at least according to the local paper. The Smart Room includes a clinical dashboard, an RTLS-powered Room Wizard, integrated medical devices, and an interactive patient station that includes schedules, goals, and entertainment. It sounds pretty cool.
St. John Providence Health System (MI) chooses eClinicalWorks for its 3,000 physicians.
The FCC and FDA will partner to promote wireless-enabled medical technology, including making their respective areas of jurisdiction clear and easing regulatory red tape.
Odd lawsuit: a woman settles her lawsuit against Quantas after claiming the airline is responsible for her deafness because it didn’t protect her from a screaming three-year-old in an adjoining seat. The woman, who wore hearing aids before the incident, told a friend, “I guess we are simply fortunate that my eardrum was exploding and I was swallowing blood. Had it not been for that, I would have dragged that kid out of his mother’s arms and stomped him to death.”
The views and opinions expressed in this blog are mine personally and are not necessarily representative of Texas Health Resources or its subsidiaries.
The Authentic Leader (Death to the Cliché)
Summer of ‘86. The gas chamber awaited me.
This time, I made sure my protective mask was on correctly. Four years prior, at basic training as a seventeen-year-old, I had panicked and failed the test. Today, during the final days of training before being commissioned as an officer, I entered the tear gas chamber and approached the awaiting officer. Removing the mask, I stood at attention, mostly. Dry heaves bent my body in half.
The commander yelled, “Cadet Marx, do you have what it takes to lead your troops in difficult situations?”
“Yes, sir,” I gasped. Do. Not. Panic.
“Do you really have what it takes? They need courageous leaders, willing to lead by example.”
“Yes, sir!” The stinging gas closed my eyes to slits. Mucous cascaded over my lips and chin.
As if he knew my struggle, he kept me longer. “Cadet, I want you to sing the national anthem.”
Crap. I gave it my best shot. I’m certain I missed a couple of lines. But as I ran out the exit and filled my greedy lungs with fresh air, I emerged a leader. I now had an authentic story.
I’ve tried to never ask a subordinate to do something I would not do, or haven’t done. I’ve scrubbed toilets and worked factories with the best. Those leaders who pontificate on theories they don’t practice get zero respect from me.
If you say, “Go to where the puck is going,” do you know the precise nuance of that statement? Have you played hockey or just watched it?
“Pace yourself. It’s a marathon, not a sprint.” How many can relate to the effort it takes to sprint or run 26.2 miles? Probably few.
Although I hate clichés, I’m guilty of using them. I do my best to speak from direct experience. The difference between telling your own story and using a cliché comes down to credibility of message and messenger.
Where I work, our strategic plan is centered on climbing a mountain, to include base camps and a summit. At first, I thought I understood the immensity of what it meant to conquer a mountain, though I struggled to articulate the concept. I’d never done it. Sure, I walked a trail to the top of Pikes Peak in my youth. But climb a serious mountain?
I asked my fellow leaders if any of them had executed a technical climb. None had. So a few of us got together and planned a climb.
During our nine months of preparation, we lost 60% of our team. We invested, we studied, we sacrificed, we trained. Boy, did we train.
On July 17, 2010, five tired but exhilarated officers summited Long’s Peak. There, we unfurled our organization’s flag, a moment we’ll cherish for years.
“Climb a mountain” took on an entire new meaning. We realized the sweat it takes to reach base camp. We faced the risks involved and the saw value of the teamwork required. When we speak with our respective employees, we can genuinely convey the energy it takes to reach a summit — genuineness based on experience.
By definition, leaders are in front guiding by example. Leaders explore. Just like in mountain climbing, leadership is risky, which is why so many stop actively showing the way. Sadly, some become active antagonists. I’ll save that for a future post.
Practicing visionaries. I believe a CIO cannot rely on how he or she operated 20 years ago or even one year ago. Don’t just talk about social media, live it. If you personally don’t tweet, yam, yelp, blog, etc, then don’t bother preaching about social media. You’re only lowering your credibility.
Patient care is shifting to the home setting, which means the virtual patient has arrived. Are you virtual, or are you still tethered to a landline in an office?
Do you discuss Mobile Health, HIE, Connected Health or Cloud, yet not actually deliver? I’ve encountered CIOs who talk HIE at length and could exchange information tomorrow, but they refuse to take action.
Your presidents face P&L pressures. Have you run a P&L center to make yourself aware of their challenges?
The healthcare industry has adopted electronic health records and has transitioned to a paperless environment. Are you still reliant on paper?
I wonder how many leaders grasp the double standard they communicate to their people. We talk about patient accountability, but is our physical fitness and lifestyle up to par with our vocation?
Finally, list the modifications you’ve made to your leadership style in the last two years. How have you adjusted to the emergence of multiple generations in the workplace? When you pass people in the hall, do they whisper, “He’s old school”?
Leading via clichés might make communication easier, but our people deserve more. The next time you hear grandpa’s hackneyed truism come out of your mouth, take it captive. It’s time to develop your own experienced-based story that will increase your credibility. Allow a cliché to catapult you to try new things and live your own genuine story.
Ever thought about climbing a mountain? Pick the peak you need to summit, and elevate your authenticity.
Ed Marx is senior vice president and CIO at Texas Health Resources in Dallas-Fort Worth, TX. Ed encourages your interaction through this blog. Add a comment by clicking the link at the bottom of this post. You can also connect with him directly through his profile pages on social networking sites LinkedIn and Facebook, and you can follow him via Twitter – User Name “marxists.”
From LookingForAnswers: “Re: Epic. They’re winning deals like Cerner did 15 years ago when they were small. Cerner seems to be a revenue-churning machine that the public can participate in by buying stock. The only people who benefit from Epic are the owners and/or Judy. Which company has made more millionaires? Which company will change the face of HIT for the long run?” Here’s the real question: why can’t Cerner, with all its billions in market capitalization and name recognition, compete with Epic for new sales? As has been asked of other Goliaths (Microsoft, GM, Dell, GE, etc.) how could Cerner, given its ample lead time and resources, let the once-tiny David called Epic beat them year after year? My theory is threefold: (a) even entrepreneurial big companies naturally evolve into highly ineffective corporate bureaucracies that are motivated by fear and executive entitlement, the antithesis of innovation; (b) publicly traded companies let their numbers drive their business instead of vice versa, and (c) corporate Darwinism would have Cerner just buying Epic outright, but Judy throws a wrench into that evolution by refusing to sell the company.
But all is not lost: we don’t know Epic’s profitability, so Cerner may be beating them where it counts. And we know that Cerner has built a business that could weather Neal’s transition or sale to another organization, but we don’t know that with Epic. What I care about most is why Epic beats Cerner for every important deal, which would seem to indicate that Millennium isn’t up to the task. In other words, a $6 billion market cap company with a single, fairly low-rated product line that’s getting hammered by a smaller and much higher-rated competitor should think about developing a better product. Here’s another way to look at the value of ongoing R&D: the only company that beats Cerner consistently in new sales is also the only one with a newer product.
From JA: “Re: Epic. More details on the Yale and Epic adventure.” Yale Medical Group describes their plans for Epic, also mentioning that a CMIO will be hired who will share time with the School of Medicine and Yale-New Haven Hospital. The specific Epic features that seemed to seal the deal were the obvious ones: ambulatory-inpatient integration and MyChart, areas in which Millennium is clearly inferior.
From Dave U. Random: “Re: Epic. Google RGHS+Epic.” Rochester General Health System has chosen Epic.
From SEC Fan: “Re: University of Michigan. CareWeb does many things well (less than they claim), but they have installed Eclipsys Sunrise over the last five years for inpatient. Interesting that after 3+ fails at EMR, they get one right and now replace it.” Thanks for reminding me. That’s another big Eclipsys loss to Epic, six years after the contract was signed and less than two years after Sunrise went live at UM.
From The PACS Designer: “Re: Windows Phone 7. The mobile phone marketplace will have more competition soon, as Microsoft has announced the beta for Windows Phone 7.” It had better be good if it’s going to displace the iPhone, Android, and BlackBerry this late in the game. I don’t see Microsoft as being good at come-from-behind victories; it’s better at running a prevent defense to protect the leads it generated a couple of decades ago. On the other hand, Windows 7 was a hit, so maybe they’re finally getting it.
From Vendor CEO: “Re: HIStalk. I have really enjoyed watching your progression. It’s kind of like watching the New York Times and Murdoch sites (HIT rags) try to get customers to pay for their sites while hordes of readers are rushing to all the free specialty news sites (HIStalk). Fascinating!” Thanks. Maybe I’m the open source alternative, a marginally skilled but enthusiastic spare bedroom pseudo-journalist trudging home to a PC after a long day at the hospital.
Listening: new from Grand Mal, which sounds like the Rolling Stones playing a smoky New York club in 1973.
Tom Ogg is named CIO of Akron Children’s Hospital, coming from Oakwood Healthcare Systems (MI).
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Not many readers think the final Meaningful Use requirements are too hard for providers to meet, but beyond that, it’s pretty much even as to whether they’re too easy or about right. New poll to your right: who benefits most from Most Wired-type awards?
A reader mentioned a JAMIA article last week, eliciting only a general reply from me since I didn’t have access to the full text version. Thanks to the folks at AMIA, who read my comment and hooked me up with anonymous access to their site so I can give a better answer next time around.
This from Weird News Inga: a medical practice sues its landlord over rights to a meteorite that crashed through the roof and into their examination room. The landlord claim it belongs to them, but the doctors say the landlord plans to renege on their promise to sell it to the Smithsonian for $5,000. The doctors say they’ll honor that deal and send the money to Doctors Without Borders for Haitian relief.
These rumors come up all the time, but once again Oracle comes up as a potential acquirer of Cerner. An Oracle VP supposedly claimed the company will spend $70 billion on acquisitions over the next five years, which always leads to talk about vertical markets such as healthcare, which means Cerner.
Duke University researchers develop software to predict MRSA drug resistance, offering it free to researchers.
Interesting: All Children’s Hospital (FL) will become part of Johns Hopkins Medicine (MD). In related news, the governor of Maryland wants to position the state as a health IT leader, citing a statewide HIE, EHR implementations, and recruitment of HIT professionals.
). Been loving your work for many years now. I don’t know how you do it, but keep on doing it.” Thanks. 
