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Foundation Members:
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CHIME Presents:
The CIO’s Guide to Implementing EHRs in the HITECH Era
CHIME Member Comments on
Chapter 2: Assessing Incentives for Meaningful Use and Weighing them Against Costs
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Question posed to members:
Comment on how you are assessing incentives for achieving meaningful use and weighing them against the costs of EHR implementation. How are you working with your senior executive team to assess costs, ROI and potential ARRA reimbursement?
Comments:
“This really isn’t an issue for us as we already have had an EMR that is fully installed in the ambulatory areas and already were underway with CPOE in our inpatient setting. Our challenge will be resolving the gaps such as 10% use of patient portal. We will use any of the incentive money to motivate the providers to compliance.”
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“We have decided to replace our legacy hospital information system, have fully evaluated three vendors and are in the selection process now. One of our selection criteria is the ability of the selected vendor to partner with us to achieve full stimulus funding and defray the cost of the new system.”
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“We are just beginning our journey (five hospitals, 28 practices, 45 locations). We were fortunate enough to have received a grant. Even with this assistance we are having very challenging discussions of ROI, patient care, affordable primary care, etc. Many questions exist as to the standards, requirements and resource availability (future incentives, available skilled workforce, vendor readiness, etc.) We just had an excellent start by hosting three regional strategic planning sessions that were very well attended. These sessions focused on achieving common understanding, setting strategic goals and planning the next steps. Now we are going to each hospital and practice to build on what we started. Even though we all realize the urgency of the timeline we have to work with, we are (trying) committed to setting a solid foundation with a shared vision, goal set and a comprehensive plan to support the project.”
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“We have used calculators from various sources to determine our incentive payment potential. I developed a gap analysis of our current IT environment vs. the MU criteria and discussed this with our primary HIS vendor. We fortunately are on a certified EMR platform as of a recent upgrade and already own all of the modules we need to achieve MU as proposed. We are working out a schedule for implementation of CPOE to meet the 2011 deadline. The incentives are not driving this process. Our current strategic and tactical plans already called for implementation of the necessary technologies within this timeframe. Our Executive Team has been advised of our situation and plans. Costs include implementation (likely using some consulting assistance) and adoption of evidence-based tools.”
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“First of all, our organization is awaiting the final rulings before getting overly involved from an operational perspective. We've got an EHR deployed for inpatient and ambulatory operation, but it's unlikely that we'd meet all the MU measures due to the fact that our activations began before 2005 and we've changed dramatically. The biggest challenge for those who already have the system installed is the evaluation of processes to ensure that we can undoubtedly prove that we use the system meaningfully.”
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“We’re not doing a formal ROI study. We had made the decision to replace our Clinical System before ARRA. ARRA just sped up the timeline. We consider it to be a cost of doing business and it will provide better quality care. Our finance team is not counting on the ARRA reimbursement in any financial modeling. There are two presidential elections and four congressional elections before the final payments are made.”
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“Our biggest concern is that we rush into something in order to meet the timeframes set out for the incentives and, as a result, create a number of future problems or do something to actually make the environment less safe. We have been implementing an EMR in the ambulatory setting for the past few years, and are farther ahead than we are in the acute care setting. We have decided to focus on achieving meaningful use in the ambulatory setting rather than being too aggressive in trying to achieve CPOE in our acute care setting in an approach that is too rushed. We are continuing on our plans to implement our acute care EMR and CPOE, but are resisting the urge to accelerate our implementation just to meet the incentive deadline. We have also done an extensive benefits realization analysis. While the incentive dollars are significant and very real, we recognize that the true ongoing benefit we will receive is through improved efficiency, quality, and safety. This is all the more reason to proceed in a way that improves our overall efficiency and effectiveness, rather than checking off a requirement on a list.”
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“Our organization conducted a gap analysis of current deployed functionality versus the final ONC recommended MU standards along with HIMSS Analytics Stage 7. We then worked with our EMR technology supplier to develop a MU / HIMSS Level 7 compliance package cost and compared to the AHA calculated incentives. Except in year one - 2010, we tied our compliance payment stream to expected incentive payments and signed a comprehensive contract with our vendor. The cost of compliance and achieving HIMSS Level 7 capability approximately equals the amount of expected incentive. Prior to signing the contract, we conducted a series of awareness sessions with our executive and management team. The first step of the project is to upgrade our EMR /PACS / audit tracking capabilities. Then we will be completing projects to comply with the current definition of Stage 1 MU. This Winter, we will kick off our one year Stage 2 / Stage 3 / HIMSS Analytics Level 7 project which will add bar coded med administration, medical device interoperability, HIE operability, physician documentation, e-prescribing, and electronic discharge processing. We hope to complete this by 1st quarter 2012 giving us the remainder of the year to comply with ICD10.”
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“In our hospital system, government relations are responsible for providing the formal estimates of the potential HITECH incentive payments. These have been broken out by hospital and eligible provider for both Medicare and Medicaid. We already have a fully deployed EHR but estimate that it will cost us $20 million over three years to meet the Stage 1, Stage 2 and Stage 3 requirements. Our goal is to have all hospitals and eligible physicians qualified by the end of 2012 as this maximizes the incentive payments.
We have regular updates with our leadership, including the CEO and COO on the HITECH project and incentive payments and have an EHR Strategy Committee, made up of senior leadership responsible for implementing required changes and ensuring that we achieve the full incentive payments. We expect to have five hospitals qualified this year and 5-6 in 2011 and 2012. Because of the impact of the 80% CPOE requirement for eligible physicians, most of these are targeted to qualify in 2011 and 2012.”
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“We have used the calculators to assess the amount we stand to receive and keeping that as a number we report to the board as we ask for approvals on new purchases.”
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“I’ve been tasked with following the MU and other ARRA related activities. I pass summary information to senior leadership and provide assumptions related to the impact these types of processes could have on our operations and strategic plans. We’ve completed an internal gap analysis and have worked through a detailed process with our primary clinical systems vendor. The calculations related to potential incentive payment are a straight forward calculation and have been projected. We have also compared our potential incentive payments against the projected costs for not only the additional applications required to meet the current MU regulations, but also the inclusion of several additional applications that are already on the strategic plan. I’ve also worked through a ‘red light, green light’ type of grid that provides a very visual presentation of the areas that need the most focus.”
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“I’m a CIO at a privately-owned, multi-specialty clinic. We began our EMR implementation in 2002. We are in a good position for MU and are awaiting compliance by our EMR vendor to meet requirements. In regards to implementing an EMR, we have done so in several ways. Initially, we did a modular rollout as we were introducing technology at the same time. We have since brought on new practices and gone live with the big-bang approach. Recently, we upgraded our EMR. This upgrade was unlike others as it represented a definite change to system workflow; so it was similar to a big-bang approach performed on single practices. While we did experience issues after the upgrade, the preparation and training for the upgrade was handled very well. There was not a great deal of information available when we began our EMR journey. It would have been great to hear lessons learned from someone like ours in 2002.”
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“Since we are fairly far along with the implementation of our EMR (HIMSS Stage 6), we are looking at the specific areas where we are not yet compliant and developing plans to meet these specific requirements. Among them is the requirement to make an electronic version of the patient’s discharge instructions available. Our vendor is tightly aligned with us in this endeavor.”
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“Nothing too rigorous. We were already on the road to EHR adoption so the CFO, using the available formulas, calculated potential incentive payments. We're not considering the cost of ROI since we already made the decision that it was necessary for business.”
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“Incentives are being considered for the EP space, but since the hospital pays for all IT cost and is looking to expand IT staffing in this space the percentage would be lower. We had our clinical vendor present a 4 hour meaningful use workshop that was focused on what the vendors and hospital need to do for stage 1 and some expectations on phase 2. We had attend coo, another general VP, CMIO, CNIO, IT leadership, HIM, admitting, directors from lab, rad and pharmacy....we needed more representation from finance.
We have also transformed our quarterly clinical IT task force meeting into 1/2 MU and back to a monthly format (I also created a MU dashboard that focused more on milestones (code, implementation, etc.).The next step is to press each initiative. The EP space is much more complex and we need more effort in this area. Also we notified our primary vendor that we are targeting measurement starting October 1 for the hospital. We expect heavy support from them...
Since ARRA will force organizations IT efforts toward clinical quality initiatives (which is scary, but correct) the goal with c-suites and clinical chiefs is to continue to trump the convergence of IT with quality and therefore the new IT is an enabler. Work the conversation into all your current governance processes....try not to create new governance
To answer your questions directly, we are within striking range of hospital MU Stage 1in 2011, therefore no ROI... 2012 needs quality capture and reporting package from vendor.”
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“We developed a seven-year strategic IT plan back in 2007. After careful analysis, we plan to stay the course and not attempt to rush our implementations in a hasty attempt to receive incentive payments. The total cost of our project (clinical and business IT solutions) is $32M. The ARRA reimbursement is estimated at $6M. The ROI amount is $3M. Hence, we are staying the course and not looking to accelerate.”
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“Our health system was working toward advanced clinicals, CPOE, and all of the positive patient quality outcomes that result from an engaged organization from the top-down before stimulus ARRA reimbursement was even a consideration. The addition of possible ARRA reimbursement now gives our health system and physicians an added incentive to moving quicker on our journey. The stimulus and its high visibility has rapidly changed physician's engagement toward an HER. No longer is it ‘a nice to have someday but too expensive,’ to a "’I need it for my practice and our patients in order to stay competitive and give the best care possible.’ In this situation, the ARRA reimbursement has done more to change provider's opinion in a rapid way than evidence- based practice adoption has done historically.”
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“Our EHR program was initiated several years prior to ARRA/HITECH as a foundational component of an overall clinical transformation initiative driven by IHI findings with senior executive sponsorship. We see the incentives as an offset for the cost of EHR implementation. We have assigned a mid-level manager a full-time role to track and report MU readiness across all hospitals and EP’s. My organization is part of a multi-hospital system across six states.”
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“Yes, we are working with our senior executive team on MU and have established a core team tasked with MU achievement. Our organization is well underway with an EMR implementation in 14 hospitals; 4 are live now. Based on our initial assessments as well as vendor assessment, we feel we are in good shape and well on our way to MU achievement. We have assessed our current state and planned activities against all MU goals, and have scored progress and know where need to focus. Additionally, we are working with state HIE’s and other similar entities. Our executive team is well aware of the monetary potential of ARRA as well as how MU relates to the reimbursement. While our EMR implementation began before ARRA funding was announced, we have tweaked timelines and targets to maximize reimbursement potential. ARRA/MU is only one component (albeit an important one) of our overall decision-making for our EMR and benefit realization.”
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“Ran the numbers based on our Medicare admits. Assuming we will be compliant. Have presented preliminary gap analysis.”
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“When MU was clarified, the CFO researched the incentives as well as the costs for non-compliance. I developed a schedule of software and processes that would needed to meet MU. Then we presented these findings to the IT Steering Committee for discussion. After lengthy discussions as to need, cost, and quality it was unanimously decided to move forward. From that meeting I entered into contracts with our vendor partners. Thankfully my CFO and I were quick to react and were able to secure implementation dates that will allow us to meet the MU deadlines. However the cost to meet MU greatly exceeds to the incentives payment. However, if penalties are factored in over a 10 year period the cost is pretty much a wash for us. The IT Steering Committee knew we needed the technology anyway and would have implemented it at some point. So for the most part we are done with the ROI.”
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“Our hospital system is using our auditors to assist with the financial analysis. We have created four scenarios of opportunity and cost associated with expanding MU technology across our integrated delivery system. Details of the plan are shared with various Board and executive committees. Final decision on pace will be made by the senior executive team with recommendation from the enterprise IT Governance Committee.”
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“We have been working closely with our reimbursement department to determine the applicable revenue resulting from meaningful use compliance. We have also begun the effort to scope our gaps in meaningful use and determining the costs; both capital and operating, to close the gaps. We have created a one page summary report, pairing the expenses with the reimbursement for senior leadership and board members that we will continue to update as the rules become final.”
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“For reimbursement estimates we used the ARRA reimbursement calculator forwarded to me from the hospital association. Our reimbursement specialists entered the variables for us and kicked the tires on the model. The biggest unknown is on the timing of incentive payments. We worked with our vendors and received quotes to move to their targeted MU release and any additional modules needed and compiled a timeline. Biggest issues were final definition of MU and certification. We did both of the above for our inpatient and ambulatory EMR strategies. We estimated the physician reimbursement impact for employed providers and the total community of provider impact (supporting our community hospital mission). With a bit of ARRA education on the front end along with the above, I presented and received board approval to proceed”.
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“At our facility, we have agreed that we intend to pursue the full incentive monies for our hospitals and practice, appreciating that the HITECH effort generally aligns with EHR-related strategies already underway – timing and new federal requirements being the additional effort. We performed a high level gap assessment and reviewed the same by mid-January – it was in-flight as the IFR was in development. We have now agreed to how we will manage this effort and its interdependencies across the organization, including where some additional project efforts must be sponsored/chartered. We also have programmatically pulled requirements from each of the five key tables in the IFR and cross referenced them to existing and new EHR-related efforts so that our PMs have the requirements necessary to plan into their work. We are revisiting costs for planning assurance. However, as these are for the most part things that we were either moving forward already or agree that this is the right thing to do, the incentive money is generally reviewed as a cost offset to a necessary investment.”
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“Our EMR is well underway already. We've identified that we need to upgrade or system, which we would have done anyway, and what it will take to make sure all quality reports will be produced. Our vendor is assisting with that task. It is not whether the incentive supports our installing an EMR, as we already have, but what it will take to tie the loose ends.”
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“In the late summer of 2009 the finance department did a calculation to come up with the benefits (over the next five years) and calculated the advantage to proceed with the selection, purchase and implementation of an EMR with 100% CPOE. As for MU, so far that is illusive but the company we are using is one of the larger ones and we were comfortable they would make sure it was compliant when the final rulings/who is going to define and judge what it means to have MU systems.”
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“We are progressing along the same path started before there was a MU requirement but it has caused us to be a little more deliberate and focused in the planning. We are comparing what we have against what we believe we need to accomplish the MU requirement. We are also putting dollar amounts to it. We are doing this with help from our HIS vender, third party software venders, and consulting partners.
Because we previously chose to implement nursing documentation before CPOE and aren’t currently on a certified version of the HIS, we already know we can’t meet a deadline of 2012 for Stag 1. We believe we will meet Stage 1 by FY2014. The goal at this point is to get whatever stimulus funds we can and avoid any penalty while deliberately improving quality and avoid any serious issue in taking care of patients.
The senior team will review the list of necessary software, the timeline, and estimated cost. We will also review software modules that might be considered to improve, quality, efficiency, and/or productivity but there is general thought we will have all we can do to meet the minimum requirements. To do more would break the bank and we are not sure we won’t do that anyway.”
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“Good news and bad news. Since we’ve been working on EHR adoption for years – we’ll go live with our first CPOE initiative in February, most of the costs have already been incurred. So, we view the incentives as reimbursement (to some extent) for past expenses. At this point, we project that the costs to comply with Stage 1 will be about 30% of the potential reimbursement. The other argument we use is simply – ‘we are doing this anyway, this gives greater impetus to complete it’ since it will affect everybody in the country.”
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“Our hospital system was on a path toward implementing a robust EMR for acute care services before ARRA was passed by Congress in early 2009. We have completed implementation of approximately 50% of the technologies that will allow "meaningful use" of them to occur. With the proper training, we expect our physicians and nurses to be using the full EMR "meaningfully" by mid-2011. As stated in various places, the ARRA incentives will be funded by cutbacks in the Medicare program; as such, we expect that these Medicare reductions will offset any MU-based incentives. In short, the MU incentives are not a factor in our decision to continue with our EMR implementation program”.
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“We’ve had an EMR program underway since 2005, with CPOE having been implemented in 2007 before our move to a new facility. At this point, the incentives are really a post-implementation ‘recovery bonus’, and will only cover about an eighth of our initial investment in the EHR program.
We had our finance department help calculate our incentive opportunity based upon our Medicaid discharges (we’ll qualify as a Children’s Hospital, under the Medicaid incentives program). Our faculty physicians may also qualify as Eligible Professionals – depending upon the final definition of that qualifier.
Our executive team has been educated about ARRA, MU, our incentive potential, and approximately where we stand today in terms of readiness (at least relative to the preliminary MU criteria published in December, 2009). We’ve asked our chief quality officer to be the business sponsor of our MU compliance program, and it will be tightly aligned with our EMR optimization efforts, and governed by our EMR Governance and IT Steering Committees.”
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“While we are hopeful to fund and attain some if not all of the MU incentives, that is not our main goal. As we recognize we only have one chance in many of these advanced clinical systems implementations, getting the system in right trumps just 'getting it done'. That said, while ARRA has created a visibility change in IT capital spending, it hasn't had a direct impact on the reality of increasingly constrained budgets.”
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“We had already started on our implementation path with an associated timeline prior to the ARRA federal mandates and MU. So, we really aren't looking at assessing incentives for achieving MU and weighing them against the costs. We aren't looking at ROI because this is something that we need to just ‘DO IT’. The reimbursements are a really nice bonus though. Now, in our community of affiliated physicians, we are educating them on the costs and incentives of MU and are trying to provide discounted vendor solutions for their implementation. We will then be interfacing them to a local HIE product so the exchange of information can occur.”
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“We embarked on a review of the incentives as soon as the information was made available in 2009. Since we were well along the path of implementation our incentive review did not go into weighing the amount of the incentive with the costs. We are going to continue along this path regardless of the amount of money received. Our assessment focused on forecasting the amount of the incentive and in which year we could expect it given our IT strategic plan. Our finance team worked with the calculators available to create an estimate. That information has been shared with our executive staff. Our senior executives approved the use of our information technology steering committee to create a sub-committee who will guide the projects needed for to meet the MU guidelines.”
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