EHR Incentive ROI – Your Milage May Vary

Our first hospital to attest for EHR Incentives is expected to receive $3,173,094 for Stage 1. To qualify for that incentive we spent $381,133. This includes the cost for 5,219 hours of IT time to complete the work.

So, it surprised me when I was listening to a CIO discuss Meaningful Use on one of the podcasts. He stated that Meaningful Use was an underfunded mandate. That is far from our early experience at Ministry.

I don’t think either of us are incorrect. We just appeared to be starting from different positions and we took different paths to attest for Stage 1.

In our pursuit of the EHR incentives provided under the stimulus bill we piloted one hospital to create a standard approach for the remaining 14. Our pilot site was our most technically sophisticated hospital, so the work to be done was less than typical. In fact, this hospital (Ministry Saint Clare’s Hospital in Weston, Wi) is an all digital hospital that has had virtually all orders entered by physicians since 2006. We have invested over $100M in IT at this hospital, it is rewarding to know that we made decisions that positioned us well to achieve Meaningful Use. This incentive money offsets a small portion of that investment.

I believe that the effort to get this hospital positioned to attest for Stage 1 was as close to minimal as any hospital in the country. In my mind this is a best case for return on investment. Our remaining hospitals will be closer to break-even.

One thing that is not significantly different between my experience and the CIO on the podcast is the software. We both use GE Centricity Enterprise as our core HIS system. However, we did self-certify Centricity (and a collection of other EHR technologies) rather than upgrade to GE’s certified version. This also saved us money and allowed us to move quickly.

Someone Else’s Meaningful Use Rant

Dr. Michael Koriwchak writing for the Wired EMR Practice blog:

“And our EMR use, our quality of patient care and our practice efficiency is for the most part no better.  In some ways it is worse.  As a result of MU”

I can see how that can happen. It is important that we hear the skeptical and the inspiring. The post is worth the read and the author’s candor is important.

Meaningful Use Rant: Quality Measures

I am writing this post, with the intent on writing a series of rants about the Meaningful Use objectives that must be met in order to secure the EHR Incentives made available by the economic stimulus bill.

Let’s start with the Meaningful Use Quality Measures. I believe this is a huge missed opportunity. We will accomplish them using the same tired back-end abstracting approach that we have always used.

I believe the quality measures will fail to be a tool for caregivers to monitor safety and quality; nor will they create a means by which payors, government or consumers can compare quality.

All of the report specifications are written using SNOMED codes and we do not use that medical nomenclature today. In fact, virtually nobody uses SNOMED. Why not write the quality measures using medical descriptions?

But, the real kicker is that everyone is rushing to measure something without talking about the clinical processes and the appropriate place and way to capture the data in real-time. If we want to be able to have good comparisons, we need to have comparable clinical processes.

Each measure requires thousands of hours of work to design the right clinical workflow and IT processes. But, instead of having objectives that define best practice for managing care and capturing data in real time, we jump straight to measurement. We skipped the most important step.

Simple example: 8 of the 15 hospital EHR Incentive quality measures deal with stroke. At what point do we know that a patient is a stroke patient? Is it when a stroke nurse completes a stroke assessment? Is it when the radiologists reads the brain scan? Is it when the attending physician reviews the CT interpretation and makes the diagnosis and instructs the nurse to begin a plan of care?

Assuming one of these is correct, then a hospital’s EHR would need:

  • a codified stroke assessment form;
  • the ability for the record representing the CT scan of the brain to be flagged by the radiologist (or rad tech) as indicating stroke; and/or
  • the the creation of a stroke plan of care.

There are NO meaningful Use objectives for any of this. Are hospitals using EHRs to monitor stroke in real-time and take corrective action when proper care is not given? Almost none. Instead, a human being will read the hand-written notes and dictated physician reports then key ICD-9 codes into the EHR. Those will then be translated into SNOMED codes to populate reports.

All of this will take place long after the patient has left the hospital.

Replacing David Blumenthal

It appears everyone was surprised by the announcement from ONC HIT Coordinator Dr. David Blumenthal that he will be departing his government post to return to academic life. By all accounts he is a great guy and I wish him all the best.

[edit: One of our Clinical Informaticians pointed out that this has been rumored for some time and Blumenthal himself said his stay would be limited. So, in the sentence above when I say “everyone was surprised” – I guess I meant I was surprised]

I would suggest that when Dr. Blumenthal is replaced, the administration should appoint someone that has a more intimate knowledge of the reality of health care IT operations and what it really takes to achieve healthcare IT objectives. Another candidate from academia would not be the right choice. I would suggest someone with hands-on, in the trenches, implementation experience in a variety of healthcare provider settings is what is needed now.

Many of the current rules for EHR incentives just don’t make sense or lack necessary definition. There is too much focus on alphabet soup, and not enough on common sense. Just to be clear I support the implementation of standards, but they have to be relevant standards and they have to further the goals. Let me give you some examples of EHR incentive rules that seem to be rules, for rules sake:

  • Problem lists are great and needed. But the certification requirement that problem lists use ICD-9 or SNOMED coding is wrong-headed. There is a ton of time being spent mapping ICD-9 codes to problems for no true benefit. The mapping is highly subjective and the end result does not create something that is reliably shared between providers that are not sharing the same EHR implementation. This time could be better spent developing care plans and interventions that help patients get to goal reliably and less expensively.
  • I love the patient portal concept and the notion of giving patients access to their medication list, allergy list, problem list, etc. But, the certification requirement that one must do this using the emerging CCD or CDR formats is using the wrong tool for the job. These standards, once mature, should be great for sharing records between providers. However, this is useless to a patient and another place where we are spending time on something that is not getting us closer to the goal.
  • Why are the NIST specifications for quality reports written using SNOMED codes? Nobody has this information in their EHR coded in SNOMED. Now the burden is on each hospital and doctor to map these codes to ICD-9. A total waste of time.

I am hopeful that an ONC HIT Coordinator with more direct experience can:

  • write sensible rules, that are not ambiguous;
  • keep the scope of the objectives achievable in the set time frames; and
  • make sure all of the work required is work that gets us closer to the goals of more safe, effective and efficient care.

Since I am posting this on Super Bowl Sunday, I have to say: Go Pack Go. This is a big day here in Wisconsin.