All I want for Christmas is ARRA answers

It’s December and I am excited. Sure, I am excited for the holidays, but I may be more excited to see the official ARRA “meaningful use” guidelines.  The HIT Policy Committee’s draft is simply not detailed enough to use to develop a good IT Wishing for a reasonable definition of "meaningful use"strategy. There are so many vendor assertions being made that have multi-million dollar implications.  Here are my top questions I am wishing will be answered when the the first draft of the rule is published:

1. Is the hospital CPOE standard for inpatient orders, or all orders in the hospital? A number of sellers of Emergency Department vendors are asserting that hospitals will not be able to accomplish meaningful use without their software.  Implementing an Emergency Department system before October 2011 is a big deal.

The meaningful use matrix does state that the 2013 standard for meaningful use is “CPOE for all order tpye.” But it also states that the measure for CPOE is “%  of all orders entered by physicians  through CPOE [EP, IP].” Can I presume that IP means inpatient and that the measure applies to order entered on inpatients?

2. In writing the official rule, have those charged with setting the standards realized that the original standard is not acheivable by the vast majority of hospitals?  Given that it has taken the writers of the rule a year just to describe what they want done, it is probably going to take more than 21 months for us to do it?

3. If niche vendors are required to achieve meaningful use, like the ED system mentioned above, do they need to be CCHIT certified? Or, does the certification requirement only apply to the core HIS? If so, what is the definition of core HIS?

Please post a comment if you think these questions have been clearly answered, or, you have questions of your own to add.

17 thoughts on “All I want for Christmas is ARRA answers

  1. Will – great questions.

    From all the meetings I’ve attended, the industry “support groups” that I belong (we all collectively sit in our virtual corners rocking and telling ourselves – it’ll be alright), and the virtual Policy/Workgroup Meetings, “IP” means inpatient.

    Some additions and concerns:
    1. OP means outpatient and they want CPOE for all orders but does this mean closed-loop and automated orders or just printing a legible order slip.

    2. 10% of orders online – does this mean roundtrip and can it be all order types? If it can just be one type, I could see implementing ePrescribing at discharge from the hospital, ED and ambulatory surgery and getting darn close to this depending upon how orders are measured (each unique instance vs. recurring orders counted as a single order).

    3. We have no solid RHIO in our area and the politics, funding and prospects to make this happen are about the same as me hitting a hole-in-one. Can we just exchange results with a relevant group of providers in our area to qualify in 2011 and then connect to the NHIN in 2013? Forget the local connectivity, it is duplicative and all the variances in State rules are going to be a bear to address.

    4. The NQF has done incredible work on defining more details behind those pesky quality metrics. They’ve run out of money and need DEDICATED RESOURCES (something you’ve blogged in the past). They are defining all the potential types of systems and how the metrics would be defined. Systems like the ED, Surgery System, Lab, and others will definitely be required or there will be some level of forms automation required in your Medical Records Software. When asking how far certification goes, it is really key to understand this. Not just that, aligning all the measures and metrics will mean significant work for our Analytics Teams along with the business process definition teams. Someone has to define the processes for this data to be reliably capture.

    5. CCHIT Certification is different than “Meaningful Use” Certification. The criteria for Meaningful Use are slimmer and they plan on adding more certification bodies. The real question is in the ambulatory space if you wanted to donate under the Stark Safe Harbor (requires CCHIT) and help your providers achieve Meaningful Use (separate certification as it stands right now).

    6. Has anyone really thought about the impact on our resources? I know AMIA and some of the researchers have (10×10 program). We are all going to go to implement at the same time and need the resources at the same time. Some of our good people will likely be recruited heavily and some will follow the money. The resources qualified to backfill them or support some of the work will not be as experienced. Pay more, get less, increase the risk, extend the timelines – sounds like a less than winning proposition.

  2. I think the key during this interim and even following the publication of the definitions is to do the right thing regardless of the incentives. These rules have a lot of potential to kick-start some good things but the devil is in the execution and sacrificing execution to achieve meaningful use will be counter productive.

    One more question that I would add to your list (although it’s not directly related to the soon to be definition of meaningful use) is “how likely is it that Cogress will stick to the penalties that are supposed to kick in”. The carrot has been tricky to figure out how to digest but how many members of congres really want to be responsibile for wielding the stick???

    At times like this I count my blessings to be working for a mission driven organization…

    Billy

  3. Pingback: All I Want for Christmas is ARRA EHR Stimulus Answers | EMR and HIPAA

  4. Gee Robin, I wasn’t and it is so relevant to what was mentioned here. I now feel so enlightened. Is everyone also familar with GE, eCW’s, Pulse System’s, PracticeFusion’s, and Praxis’ guarantees too? Thank goodness for solid marketing spam. Glad you’ve run-out of marketing channels.

    Here is an award-winning idea – start your own blog and spam yourself.

  5. With all this talk about multimillion dollar incentives for potentially employing a complicated point and click EMR/EHR (which impedes good patient care IMHO) I wonder what would happen if everyone knew that the answer is so simple and so inexpensive that we can eliminate all these vampire squid vendors who want to get all of that free money.

  6. Curious to get your thoughts as to whether the organization should know it will surpass the meaningful use requirements at the time they sign with the EHR vendor. It seems to me that those who are risk are those who did not place enough emphasis and rigor in the definition of their requirements.

  7. Paul – I’d agree with a few caveats. If you are just getting started on the inpatient side and you have any size, scale and complexity, you have a very difficult road ahead of you. I find the keys to be:

    1. Do they have the clinical content?
    2. Do they have the proper business rules and UI to make the system usable?
    3. Can they really interface with the systems you need?
    4. Do they have an integrated analytics platform that takes information from 1-2-3?
    5. Do they have the implementation expertise or enough partners so you can augment your Team to make it happen?

    There is a little more opportunity for EP’s connected to stronger hospitals and health systems. Independent EPs are going to have a difficult time complying and affording the technology.

  8. Well written Art. That’s why I’m such an advocate of a very detailed RFP, one that is attached as a part of the contract. With the uncertainty surrounding everything from meaningful use to moving the business model from 0.2 to 2.0, I think the trick is forcing the RFP to look at requirements 3-5 years out, and being creative enough to take soft requirements like ‘flexibility’ and write them into the RFP.

  9. Re: Detailed RFPs – this is why I have been an advocate for a Creative Commons-based repository for health care and health care technology-based content such as RFPs, RFP features matrices, policies and procedures, job descriptions, process flows, test cases, test plans, QA checklists, project plans and management templates, order sets, orderable definitions, care plans, clinical documentation templates, flowsheets, and the like. When I was on the vendor side of the business, my company had a goal of over 30% re-use of deliverables. We could save each other some real money by doing this. The two false starts I’ve had in this capacity have always been due to the day job. It definitely takes time. That is why I respect the active bloggers with day jobs.

    You are very correct that writing requirements that are 3-5 years out is much more of an “art form”. It really involves breaking-down the requirement into more granular components and then looking at how they would be reassembled. The latter usually links into application architecture and directional questions. I like to separate these into scenarios and have the vendors answer how they would recommend fulfilling the requirement in the current state, interim state and some future state. It needs to be linked to a development roadmap. This exercise has never failed to show holes in the vendors’ roadmaps and differences of opinion among vendor resources. It is also interesting to hear how many different ways there are to solve a problem, again sometimes from the same vendor. I also enjoy joking with the vendor that their free consulting should knock another 5-10% of the discount they are offering on both initial and on-going costs.

  10. I wonder about which technologies, which user interfaces, which processes and procedures allow for the MDs, DOs, NPs, PAs to focus on the patient, the treatment and ordering the right course of treatment rather than the mouse and key board. I know in 15 years most of the professionals will have great computer/typing skills but that’s a long time.

    Is it scanning, voice recording, touch screens, tablets, what empowers the professionals rather than shackles them?

    I have a feeling that this is to Health Care what No Child Left Behind is to Education.

    B2 (;->

  11. Meeting the Meaningful Use rules in the Emergency Department (ED) is not as difficult as some vendors would lead you to believe. Our customers often leverage the benefits of their existing CPOE and HIS vendor’s ED system. The hospital then installs the Forerun ED Physician System for physician documentation, patient discharge and more. It is interoperable with MEDITECH EDM and other systems. Our Patient View screen has a “hot button” link to MEDITECH’s CPOE. When clicked, the MEDITECH OE screen is opened and the same patient is automatically identified. Orders are entered and the physician then returns to the Forerun screen. There is no need to create a new CPOE just for ED physicians.

    With this solution, the implementation is faster and costs are reduced. (Reduction in transcription fees often pays for the system.) Meaningful Use rules focus on “…electronically capturing health information in a coded format”. Hospital focus should be on an ED system that the ED physicians will want to use for patient documentation.

    • Firstly, that seems very difficult. Secondly, there are NO meaningful use requirements for the Emergency Department. Specifically, the interim final rule explicitly states that the CPOE meaningful use standard only applies to inpatients. I am not buying.

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