Meeting Meaningful Use

Kern Medical Center embraces open source technology to achieve clinical transformation and HITECH requirements.

A hospital can spend millions of dollars on a sophisticated electronic health record (EHR), but if it's not used meaningfully to improve patient care, it's of little value.

Last year, the Health Information Technology for Economic and Clinical Health Act (HITECH) authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that implement an EHR. As a subsidy for the costs of implementing an EHR, the legislation will make incentive payments totaling up to $27 billion over 10 years; hospitals may receive millions of dollars for implementation and meaningful use of certified EHRs under both Medicare and Medicaid.1

HITECH's goal is not adoption alone, but rather to ensure EHRs are used to improve healthcare delivery and outcomes. The legislation ties payments specifically to meeting "meaningful use" standards for achieving these improvements. Starting in 2011, healthcare providers with an EHR will only get government funding for EHRs if their systems meet the meaningful use standards. The federal government will gradually reduce reimbursements to EHR adopters through 2015, after which penalties for non-adoption begin.

What Is "Meaningful Use?"

After nearly a year of anticipation, on July 12, the U.S. Centers for Medicare and Medicaid Services (CMS) released its final version of the meaningful use rules, creating a frenzy of nervous discussion as physicians and hospitals raced to understand their eligibility for incentives. The anxiety has been palpable: only about half of hospital chief information officers expect to meet the first set of meaningful use requirements in 2011, according to a recent report by PricewaterhouseCoopers.2

However, since the final regulations were announced, the scope of meaningful use has become better understood. Essentially, the requirements are divided into two groups: a set of core objectives that constitute a starting point for meaningful use of EHRs and a separate menu of additional important activities from which providers will choose five to implement in the first 2 years (2011-2012).

Most of the core objectives comprise basic functions, including the entry of basic patient data: vital signs and demographics, active medications and allergies, up-to-date problem lists of current and active diagnoses, and smoking status. Other core objectives include using clinical decision support tools and requiring clinicians to electronically enter clinical orders and, in particular, medication prescriptions.

Lastly, the meaningful use standards require electronic reporting of data on the quality of care and, in 2011 and 2012, clinicians must report on blood pressure, tobacco status and adult-weight screening, and follow-up on these key barometers of health.

From Cost Prohibitive to Open Source

Especially for county medical centers working to achieve meaningful use, the biggest concern is the cost of commercial EHR systems. Kern Medical Center, a public hospital in Bakersfield, CA, has needed an EHR for some time, but found the cost of most systems to be very high. This is the case with many other hospital systems: comprehensive clinical health IT adoption by U.S. medical facilities remains low (roughly 1.5 percent according to the New England Journal of Medicine) largely due to the prohibitive costs associated with implementing an EHR.

A 222-bed acute-care teaching hospital, Kern provides the bulk of Medi-Cal hospital services to a community of approximately 650,000. Searching for an affordable solution, Kern investigated various proprietary systems, which led the hospital to explore the U.S. Department of Veterans Affairs' (VA) VistA solution and, eventually, its commercial derivatives.

The VA has long been recognized as a model for quality healthcare and the homegrown VistA EHR has been field-tested for more than 20 years in approximately 1,300 VA sites of care, including more than 160 medical centers and 850 related clinics. In the past decade, commercial, open-source derivatives of VistA have leveraged the $8.5 billion taxpayer investment and entered the market to serve non-VA healthcare organizations.

VistA and its commercialized versions are open source, which refers to software distributed for free under a licensing agreement that allows source code to be shared, viewed and modified by others. The only costs associated with open source are fees for implementation, maintenance and support. This scenario offers a viable solution to organizations that could not previously implement EHR technology due to the cost and vendor lock associated with proprietary systems.

In choosing an open-source EHR based on VistA, hospitals can tailor the system to their facility's needs using an open architectural framework while still benefiting from VistA's reliable and integrated clinical support system. Many physicians have completed their residency training at the VA and are already familiar with VistA, which helps with the adoption process.

In November 2009, after researching available EHR solutions, Kern chose a VistA-based open-source health IT system called OpenVista. The hospital is currently in the implementation process and expects to go live by February 2011. With the first disbursement of stimulus money coming in 2011, Kern will be fully eligible for HITECH incentives thanks to open source.

Nuts and Bolts of Achieving Meaningful Use

The integrated nature of Kern's VistA-derived open-source EHR system offers significant advantages in terms of increasing clinical performance, reporting data and improving healthcare outcomes. A core portfolio of software features supports these functions and is critical to Kern achieving meaningful use.

A key component of the core EHR portfolio necessary for achieving meaningful use is computer physician order entry (CPOE), a requirement for any provider serious about garnering HITECH funds. Under HITECH, more than 30 percent of patients must have at least one medication ordered through CPOE. Studies show that CPOE reduces length of stay, repeat tests, and turnaround times for laboratory, pharmacy and radiology requests.3

Kern's system will also include an inpatient bar code medication administration (BCMA) application that electronically validates and documents medications at the point of care using a bar code scanner and integrated software application. Studies have shown that electronic bar-code technology can greatly reduce medication errors during administration and improve patient safety.4

In addition to CPOE and BCMA, Kern's EHR project will provide clinicians with access to valuable clinical IT support, including a closed-loop medication management system, clinical alerts and reminders, flexible reporting tools and a portfolio of clinical templates. The flexibility of an open-source system allows Kern to use the solution effectively from day one, and customize and enhance it over time to specific hospital needs.

Implementation and Adoption

An EHR implementation takes a great deal of planning and preparation. Hospitals that are unprepared for a health IT implementation project will have until fall 2011 to be operational if they want to take advantage of the full 5 years of HITECH incentive payments. Of course, choosing an electronic record and a vendor to work with, then building consensus among medical staff to use it, can be a difficult process. The first step is implementation, but the adoption process for staff is just as critical.

During the pre-implementation planning process, Kern worked closely with our EHR vendor and internal IT department to prepare for the technical configuration and installation of a wireless network. Hospital staff were challenged with juggling both existing operations and associated traditional IT while also planning and preparing for the new EHR project. To ensure a smooth "go-live," hospital nurses and physicians are being trained on the new system weeks in advance of final implementation and additional staffing support will be provided by our vendor the week of go live.

A key challenge is training staff and preparing for adoption and integration into the existing culture. Make no mistake, EHR implementation is a huge task and should be approached with great preparation and seriousness. But it can also be done in such a way that the benefits are clear to clinicians and hospital staff well before implementation begins. In many ways, an EHR implementation is a cultural challenge as much as an IT challenge. Administrators have to share information liberally and frequently, identify program champions and prepare for change.

Some Kern staff members were initially reluctant to change from paper to electronic processes, but they are adapting and now excited to use the technology. We believe the EHR system will create millions of dollars in savings on paper and medical record management alone. Kern estimates the hospital will be eligible for up to $11.6 million in HITECH incentives over the next 5 years, which will conservatively be almost a 400 percent return on the initial investment in the EHR system.

From a county governance perspective, going from a first meeting with the EHR vendor in August 2009 to a contract in November 2009, to having a full EHR system up and running in February 2011 is considered lightning speed. And obviously, hitting the first phase of meaningful use is very important to the hospital. We have a high portion of Medi-Cal patients, which translates into greater Medicaid and Medicare reimbursements from HITECH. That will more than pay for the VistA-derived open source EHR system we selected, and we'll realize the same improvements in patient care as hospitals that only get 20 percent of their overall health IT costs from federal stimulus.

Paul Hensler is CEO of Kern Medical Center, Bakersfield, CA.

References

1. Blumenthal, M.B., M.P.P., D. and Tavenner, R.N., M.H.A, M. The "Meaningful Use" Regulation for Electronic Health Records.  New England Journal of Medicine. Retrieved August 26, 2010 from the World Wide Web: http://www.nejm.org/doi/full/10.1056/NEJMp1006114?ssource=hcrc&

2.  Ready or not: On the road to meaningful use of EHRs and health IT. PricewaterhouseCoopers. Retrieved August 26, 2010 from the World Wide Web: http://www.pwc.com/us/en/health-industries/publications/ready-or-not-on-the-road-to-meaningful-use-of-ehrs-and-health-it.jhtml

3.  Computerized Physician Order Entry. The Leapfrog Group, Washington, D.C. Retrieved August 26, 2010 from the World Wide Web: http://www.leapfroggroup.org/for_hospitals/leapfrog_safety_practices/cpoe

4. Poon, E.G., et al. Effect of Bar-Code Technology on the Safety of Medication Administration. New England Journal of Medicine. Retrieved August 26, 2010 from the World Wide Web: http://www.nejm.org/doi/full/10.1056/NEJMsa0907115