From the July/August issue of Government Health IT.
For the nation's hospitals, information requirements of the federal government's imminent reimbursement reform initiative called value-based purchasing are starting out easy. Deceptively easy.
An initial set of 12 "core measures" of performance quality, for which hospitals must show achievement or improvement to earn bonus money, is already part of a larger measure set that providers have compiled and sent to the Centers for Medicare and Medicaid Services since 2003. The second component of the value-based formula eight measures of inpatient experiences was lifted from a survey that hospitals have mailed to discharged patients, with the results made public since 2007.
But the demands of collecting and reporting these first core measures are a snap compared with what the value-based purchasing program in particular, and the overall quality-reporting wave in general, have in store for the business of healthcare. REPORTING METRICS TEMPEST Stiffer requirements are set to emerge in fiscal year 2014, the second year of value-based purchasing. To that, add the 15 quality metrics that electronic health records must be able to report on as part of the HITECH Act's meaningful use requirements. Then consider 65 quality metrics that accountable care organizations will have to report on by the middle of this decade.
"This whole concept of having to collect information, to be turned into quality reporting, is like a tsunami coming our way right now in the healthcare industry," said Deane Morrison, chief information officer of Concord Hospital in Concord, N.H.
Those requirements call for a level of IT intricacy sufficient to collect vast amounts of clinical detail, store it in a form that can easily be retrieved for reporting purposes, and inject it into the hospital setting so clinicians can see what they need to do for patients and move the metrics in the right direction over time. "The objective is to be able to get the data and then in almost a realtime way be able to influence behaviors so that you can improve the outcome," said Dana Sellers, chief executive officer of Encore Health Resources, a consulting firm. "We're still pretty far from being able to do that." The first baseline requirement is the ability to capture this data, and the second is the ability to somehow extract it, said Jim Adams, managing director of strategic research for the Advisory Board Company. "You can't do that by abstracting medical charts by hand, the way reporting has been done up to now."
"The industry has to be able to collect the data it needs for all this quality reporting as a byproduct of the regular (electronic) charting process," Morrison said. "If you can't do that, you're sunk."
That being the case, plenty of hospitals around the country aren't ready. METRICS NOT AN IT PRIORITY The first step, obvious as it seems, is to do all the collecting and reporting of quality metrics directly in the facilitywide EHR. That may be an uphill battle, starting with changing the usual pro cess for collecting and entering quality information, said David Classen, senior partner and chief medical officer at the CSC Healthcare Group.
Thus far, the norm has been to load data into a separate IT application. "What often happens is, a nurse will abstract information out of the EMR, enter it into the standalone quality reporting system, which then reports it on to the government," Classen said.
Using clinical IT systems as the engine for quality improvement is a logical endeavor, but there's not a lot of history behind it, Sellers said.
Until about a decade ago, IT systems were intended to automate transactions in hospital departments. When the business became more enterprise-focused, the emphasis shifted to improving processes across departments.
"But what we've realized in the last few years is while that's still important, it's not enough," Sellers said. IT systems "may have accomplished a lot of good, but they did not allow us to get data captured in a way that we can get it back out, aggregate it and use it to really drive improvements in quality."
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Until the HITECH Act forced organizations to set up their systems to generate meaningful use, what passed for electronic records was often a hybrid of means to capture and store information. Clinical data collection was a matter of dictating, transcribing into notes and sticking the data first in a paper chart and later as scanned pages in a document management system, Morrison said.
"Then EMRs came around and we started to say, `Well, we want some of this data in discrete format,'" he continued. "So we started to move to discrete data."
But moving to a fully electronic record won't by itself make healthcare facilities ready to take on quality reporting, Classen said, because "no EMR has a turnkey system that automatically collects and reports quality information."
Building on that, he added, "The second question is, how many places have successfully customized their vendor products to automatically collect all quality reporting required for value-based purchasing and automatically report?" said Jim Adams, managing director of strategic research for the Advisory Board Company. "And the answer is, `I'm not aware of anybody who's got it all handled and automatically reporting without significant human involvement.'"
DATA, YES, BUT NO REAL PLAN TO TAP IT
Concord Hospital and its employed physicians have implemented ever-higher levels of EHR capability for nearly 13 years, starting with DOS-based systems, graduating to highly-functional technology from a company called MedicaLogic and, since that company's acquisition by GE Healthcare, using Centricity.
"Along the way, we've done a lot of work in that space with figuring out how to do reporting, compare it to benchmarks and engage physicians in changing," Morrison said.
Though the hospital can electronically report many value-based purchasing metrics, it's a tough task to "correlate the data to the (CMS) benchmarks and show where your gaps are, and then ... transform that knowledge back into workflows so you can do something about it," Morrison said. "On top of that, there's really no model today to turn that information around and put it back in an appropriate provider's workflow."
It's a challenge for even the most technologically advanced health systems. "I can't imagine what it's like to be a small rural or community hospital where the administrative team hadn't supported the implementation of IT and they're starting from scratch," Morrison added.
A spanking-new EHR is only part of the solution, though. "The number of people who have bought EMR systems thinking they'd turn a switch and it would print out quality-reporting information for value-based purchasing is unbelievable," Classen said. "They thought they were buying that when they bought the system. And then they find out that system was never programmed or set up to do that. And even if they did set it up to do that, getting the data out of the EMR vendor system for the kind of reporting the government wants is another challenge as well."
Health systems that have made investments in IT during the past decade, however, say it's just a matter of knowing what the reporting require ments are and organizing to ferret out the information.
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"A lot of the baseline systems are in place, so what people are looking for is how you pull information out of these systems according to certain criteria, and then how you accumulate it and summarize it and present it according to certain requirements and formulas," said Bruce Smith, CIO of Advocate Health, an eight-hospital system mainly in the Chicago metropolitan area. Nearly 80 percent of the clinical data on the inpatient side is digitized on a singlevendor information network, and twothirds of its employed medical group is up on one system and integrated among many locations.
The NorthShore University HealthSystem is positioned to both collect and analyze information at all four of its hospitals in the northern suburbs of Chicago, said Thomas Smith, its CIO. An EHR from Epic, in operation since 2003, includes all data that normally would be part of the patient chart, and a separate data warehouse regularly collects and updates the EHR data plus payroll and general ledger systems for doing reports and tracking metrics.
An organizational emphasis on centralized information technology has rendered the system "structurally ready" for value-based purchasing and other reimbursement reform, said Brian Washa, senior vice president of business services at NorthShore.
"We've got all kinds of data," Advocate's Smith said, "and now the question is, what do you want out of the data. I don't know that it's difficult to get it out once people define what it is they want." BEGINNINGS OF A DEFINED EFFORT The measure-defining process that began with HITECH quality metrics will carry over into value-based purchasing, lending some standardization and consistency to data collection and making it easier to locate and extract the information needed to populate core measures.
"There are some specific sets of data that we know there are standards for, that we can capture today, that we can build into our electronic records right now," Sellers said. "Meaningful use (Stage 1) provided the first set of standards for that, and Stage 2 is providing more."
The challenges with meaningful use around quality reporting also will carry into value-based purchasing, Adams said. "One CIO told me his boss gets a report card from Epic saying, 'Here's how you're positioned on meaningful "What often happens is, a nurse will abstract information out of the EMR, enter it into the standalone quality reporting system, which then reports it on to the government."
Capturing the data is a matter of not just clinical process but also technical advancement. There's a difference between automating what had been a manual chart-abstraction process and devising truly electronic quality measures "with electronic specifications and computer logic," said Karen Knecht, a practice executive with Encore Health Resources. That emphasis on "e-measures," which started with HITECH quality metrics, is overlapping into value-based purchasing.
Of the 15 HITECH and 12 valuebased-purchasing quality metrics, two measures relating to prevention of blood clots in surgery are common to both sets, and they are true e-measures, Knecht said. Among other things, there are electronic specifications of how to capture the numerator and denomi nator, identification of a defined set of blood-thinning drugs, and defined methods of how to capture and report information through the RxNorm industry standard for normalized clinical drugs.
"The similar ambitions for quality reporting in both programs make it all the more important not to think of them as separate projects," Knecht said. Healthcare providers "need to be thinking about quality measures relative to reimbursement reform and think about their path toward that."
The quality reporting message emanating from various healthcare reform initiatives is very clear. "There is a movement toward capturing quality measures in a discrete, standardized way through our information systems, and we've got to start doing that today," Sellers explained. "As those measures become standardized and clearly articulated, we've got to build those into our systems today, we've got to become disciplined about that, and as each new set of standards becomes clearer, we have to just roll them into our systems."
What's not so clear: Whether today's EHRs and other IT systems are ready for those new measures. bruce smith, cio of advocate Health, in the chicago metropolitan area.
