Serving as CIO of Good Samaritan Hospital in Vincennes, Indiana, Chuck Christian says he is blessed with a great team. But there's far more to life these days than running an IT department. "Some days I feel like a crow," says the down-to-earth Christian, whose staff comprises 29 workers. "I keep looking to that next shiny thing. It feels like adult ADD. It's difficult to know where to focus."
What is the source of all this distraction? In a nutshell, it's Washington, D.C. Christian's lament is widespread these days. Ask hospital CIOs about their holiday wish list, and you pretty quickly catch on to that theme.
CIOs are overwhelmed by the sheer volume of federal programs coming their way. They're finishing the year with their transition to HIPAA 5010, the new claims transaction standard that requires system upgrades and testing with payers. At the same time, they are mired in meaningful use, installing and deploying EHR systems and modules such as e-prescribing, computerized order entry and patient portals. They're hustling to qualify for federal incentives (and avoid eventual federal penalties).
Beyond that, CIOs are facing an October 2013 deadline for the conversion to ICD-10 (see cover story, page 18). That alone requires a massive overhaul of clinical, financial and administrative systems in order to keep the cash coming. Layer in other federal programs spawned by health reform-such as accountable care organizations and the shift in risk-sharing and payment methodology they represent-and you have the underpinnings of a bad dream. Factor in the push for health information exchange, and the nightmare can turn into waking delirium.
What's significant about CIO frustration with the regulatory environment is that it's coming from leaders who solidly champion clinical IT. They are not resisting government programs because they want to live with paper charts. In fact, many CIOs are clamoring for federal involvement in areas where they perceive a need-such as a national patient identifier and a broadened IT labor pool to help pull off the projects the government is asking them to do.
"My top wish is for the whole concept of the EHR to come into fruition from the national guidance perspective," says Russ Branzell, CIO at Poudre Valley Health System, which runs two hospitals in Fort Collins, Colo. "A lot of work across the country isn't coordinated. We need to get to the point that it's improving care. My fear is that nationally, and on the state level, we are doing so much so fast we may not be doing a great job. With meaningful use, we're trying to push so fast. People are doing IT projects, but they're not oriented to improve care. We're trying to slow down our own effort to make sure we're doing the right thing for the right reasons."
Branzell is no newcomer to the EHR. Poudre has been building out an electronic record for the past eight years. And the federal incentives under meaningful use-while aimed in the right direction-are creating unseen consequences, he says. "Vendors can't keep up with government requirements and CIOs are stretched thin. It is putting the industry into turmoil."
For some CIOs, the web of regulations means some efforts likely will be sidetracked. In essence, each government program is pushing against others. That's why an extension on ICD-10 is tops on the wish list of North Shore-Long Island Jewish Health System CIO John Bosco. "Not for the purpose of procrastinating," he says. "We're working on ICD-10 now and have a detailed project plan with established governance, a steering group and nine workgroups. Our fear is running into deployment plans for the EHR and Stage 1 meaningful use. We could disrupt some EHR deployments."
With 15 hospitals and 2,200 physicians, North Shore-LIJ is a complex operation. And completing the ICD-10 transition alone will be a major challenge, Bosco says. "About 130 applications are impacted," he says. "Half are clinical and half are revenue." And when push comes to shove, Bosco says the health system will set aside its EHR enhancements to qualify for meaningful use incentive payments and prioritize instead its transition to ICD-10. "We are a $7 billion health system with millions of claims going out the door. Meaningful use means less than $100 million for us. ICD-10 will be the highest priority, but we still strongly believe in the EHR."
Seconding Bosco's wish to delay ICD-10 is Mike Restuccia, vice president and CIO of Penn Medicine, which encompasses the University of Pennsylvania Health System, a research center and a medical school. Bosco says U-Penn is well on its way to attesting for Stage 1 meaningful use, merely waiting for one piece of homegrown software-its data warehouse and analytics tool-to be certified. "We have all the criteria met for inpatient and ambulatory," he says. "We are 100 percent CPOE and 100 percent physician adoption on the ambulatory side."
Despite the progress, Restuccia wishes for the gift of a 12-month postponement of ICD-10. Delaying ICD-10 would enable Penn Medicine to better tackle Stage 2 of meaningful use, as well as enhance its overall clinical IT footprint. Toward that end, the health system has several major EHR system upgrades planned to support the advanced functionality likely to be called for in later stages of the federal incentive program. "These are not small projects," he says, ticking off a list that includes the ambulatory EHR, the lab system, and the inpatient EHR.
Tackling the upgrades across the health system's three hospitals makes the project even more difficult. "When you think about multiple hospitals, the number of physicians affected, the CPOE system, results, pharmacy and clinical documentation, you'll be affecting a lot of people," Restuccia says. "Getting more value out of those systems is where we would like to focus. But doing ICD-10 at the same time is too much at once. It will need assessment, remediation and an incredible amount of testing. Something will have to give."
For Bosco, the cash flow stakes of ICD-10 qualify as reason to delay the implementation to assure appropriate industry-wide testing. "We're concerned payers won't be ready," he says. "Our fear is chaos when the switch gets flipped."
The relatively short timeframes for meaningful use-which squeezes three stages of qualifying criteria into four years-gives Christian pause as well. "We are just now getting through Stage 1, and are waiting for Stage 2 in the middle of 2012. Then we will be looking to what Stage 3 should look like, while we're just getting through Stage 1. I'm not sure how we're supposed to make good decisions for stages that are two phases away when we don't yet have a good account of Stage 1. We could go so fast we create errors."
The pace of change bothers Chuck McDevitt as well. He serves as vice president and CIO at Self Regional Healthcare, Greenwood, S.C. His wish list includes having "a longer timeline on achieving meaningful use as we are literally trying to put in five-plus years of applications over the course of 18 months," he says. "Our vendors are struggling to provide implementation teams and upgrades in a timely fashion while we're all fighting for the same talent in the marketplace."
The frenzied pace leaves CIOs worried about their staffs. Asked about his top wishes, CIO Gary Barnes says "some relief for IT staff in health care who are at that burn-out point. They need a break in projects." Barnes serves as CIO at Medical Center Health System, a 362-bed facility in Odessa, Texas. He has 45 IT staff and six openings-analyst positions which he says are difficult to fill. "They are high-paying jobs, but unemployment is low in Texas due to the oil boom. Oil companies need analysts too, and they pay so much more."
Barnes has many balls in the air. Odessa is rolling out an ambulatory EHR, from McKesson, to 135 area physicians, taking responsibility for hosting the software and assisting the physicians with meeting meaningful use requirements. Odessa is tackling the project under the auspices of another federal program-the relaxed Stark laws which permit hospitals to subsidize a portion of the EHR cost for physicians and not run afoul of anti-kickback provisions. His other projects include 5010, CPOE, inpatient physician documentation, quality monitoring, and, last but not least, a consumer-driven personal health record, which is proving to be a challenge, Barnes says. "I wish I could get the projects down by just one. We're juggling so much, and providers and vendors are stealing staff from each other trying to meet meaningful use."
The burgeoning to-do list at Self Regional Healthcare is exacerbated by labor shortages as well. That's why one of CIO McDevitt's top wishes is just to be able to find good help. "I'd like to be able to fill open positions we have for clinical analysts and developers with qualified applicants," he says. "We have several positions open, but this is the toughest job market I've seen in my career for finding qualified applicants. We are in a rural setting but are a strong regional referral center close to major cities such as Atlanta and Charlotte. We've tried advertising online and in our competitors' cities 90 minutes away without success."
Fear for the Revolution
Bosco says that North Shore-LIJ will start to attest for meaningful use in 2012 and continue on a hospital-by-hospital basis through the end of 2013. In addition to delaying ICD-10, he wishes for a postponement of latter stages of meaningful use-mostly because of the negative impact the compressed timeline is having on the industry. "I worry about the end result of this EHR revolution," he says. "We're doing fine and can afford to do it. But a lot of places can't. What concerns me is how quickly everybody is moving. There are a lot of fly-by-night vendors selling to physicians. Are these companies going to be around? We need to make sure we are doing a good job with what we are implementing today."
In Bosco's view, the sheer quantity of EHRs available in the ambulatory market is cause for concern. Indeed, by late 2011, more than 850 ambulatory products had been certified under meaningful use standards, according to the government's Web site, HealthIT.HHS.gov. "Where will we be after the big rush is over?" Bosco asks. "We have 8,000 private physicians. If they wind up with 300 different EHRs of varying quality and stability because everybody is rushing and Uncle Sam is paying, we could have a real mess on our hands. The industry needs more time to do the job in the right way."
Restuccia is not wishing for a delay of meaningful use, but he has a related dream: consistency among the latter stages of the incentive program's qualifying criteria so they'll build logically upon Stage 1. It would make sense, for example, to have a metric for increasing the proportion of orders entered electronically, and not layering on entirely new criteria. Keeping the criteria in the same vein and avoiding quantum leaps in requirements will help ensure the success of the program, he says.
Christian agrees with that idea, wishing for "clarity around meaningful use." He favors the program-and the endpoint of EHR adoption-but hopes the pace will slow down. "We're not manufacturing cars," Christian says. Changing the industry is "like turning the Titanic."
The meaningful use program is sparking other gift ideas. McDevitt wishes for less opportunism among vendors trying to exploit the program.
"I'd like to have a lab vendor that didn't see meaningful use as an opportunity to force an expensive 'meaningful use hub' on us that we should get through the normal maintenance process on the product," he says. "I'm not sure how you can call your product certified and yet require customers to purchase additional products to get there-especially when we pay a considerable amount for annual maintenance. It certainly doesn't make for good long-term relationships and forces customers to reassess their direction on the system they have in place today."
McDevitt's wish list touches on other offshoots of regulatory fatigue as well. "I'd like to not get any calls or e-mails from someone offering a Webinar or shortcut to putting in an ACO, ICD-10, or helping us to achieve meaningful use," he adds.
Despite all the issues around regulation, CIOs are not fundamentally anti-government. Christian, like many of his peers, just wants more appreciation of operational realities.
And, ironically, some CIOs wish for even more government regulation. Both Bosco and Restuccia, for example, ask for a national patient identifier. An NPI was part of the original HIPAA legislation, only to be later scrapped by Congress when the idea became too controversial. For Bosco, a national identifier would reduce expenses significantly. "We spend millions on our master patient indexes," he says. "And now we must deal with regional and community data exchange. An enterprise MPI is hard enough. And it is getting bigger and more complicated. The expense would go away if there were a single identifier."
Restuccia says his wish for a national identifier is rooted as much in safety as economics. Current identification systems-which are usually based on algorithms sorting through a combination of name, birth date and gender-are not foolproof, he says. But as HIEs blossom, the need to ensure correct matches between patients and data becomes even more important-and challenging.
Reporter's Notebook: Wishful Thinking
When I began asking CIOs about their holiday wish lists, I figured I'd come up a wide laundry list of items, such as new applications, bigger budgets, more physician involvement, and so forth, with answers as varied as the people giving them. But to put it simply, provider CIOs feel overwhelmed by the amount of regulatory imperative that is being thrust upon them. When you have multiple masters, and the tasks given by each do not harmonize, you have the formula for stress and burnout.
Most tellingly, the CIOs I interviewed thanked me for listening to them in the first place. One said that airing out his wishes was very therapeutic. Clearly, this is a group that feels underappreciated, and unrightfully so: their efforts are critical for the national vision of a safer and financially sound health care industry. So I'd like to use this opportunity to thank CIOs and their colleagues for doing the heavy lifting and pushing forward even as their burdens increase exponentially.
Lately, I have been absolutely astounded by the growing disconnect between the rule-maker and the rule-follower. The initial proposal from Medicare on accountable care organizations, for example, was far removed from anything remotely feasible. The revised version is somewhat less onerous. But just as I struggled conceptually with the notion in the first model of "retrospective attribution" of patients (meaning providers wouldn't know the identities of patients in their ACO panel until after the fact of bonus reimbursement), I now am perplexed by another idea: how could a program such as this gain any kind of foothold in an industry in which providers are so pre-occupied with other federal mandates?
In that context, here's my simple wish: for the legislators, policy makers and regulators who are involved in meaningful use, ICD-10, accountable care, privacy, disclosure, health information exchanges, data exchange standards, Stark, medical homes-and all the other regulated aspects of the industry-to spend a little quality time with the people who are trying to fulfill the marching orders before them. Perhaps they'll see that the industry needs mentors more than additional schoolmarms.
This article originally appeared in Health Data Management magazine.
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