Richard Ford, RRT, FAARC, is ready for Epic; not an epic, mind you, but Epic Systems Inc, the giant software company that is installing its EpicCare electronic health records (EHR) system at the University of California San Diego Medical Center (UCSDMC) where Ford is director of respiratory care. The 120-person respiratory care department’s EHR system will allow the professionals there to immediately see, via a computer screen, what other hospital departments have done for a patient, so respiratory can provide higher quality, nonredundant care. “We struggle with this question every day: What have the other departments done for our patient,” explains Ford. “If physical therapy found limited mobility in a patient’s right hand, why am I training him to use a metered-dose inhaler with the right hand? If nursing has given him medication that raises his heart rate, why am I giving him a different medication that has the same effect?”

To avoid those kinds of mistakes today, Ford and his staff have to weed through piles of paper from other departments. “It is a huge barrier to providing immediate care,” notes Ford, who explains that many of his patients are originally admitted through the emergency department or the trauma department. In addition, the new EHR system will allow for a more multidisciplinary review of a patient’s drug history than is currently available with the hospital’s stand-alone e-prescribing system, which will be ditched once the more sophisticated Epic e-prescribing component is up and running. Also, a respiratory department person will be able to connect to a patient’s pulmonologist or internist, whether that physician is inside or outside the hospital, and get an immediate consult while both are scanning the patient’s complete medical record.

Careful Planning Called For

The improvements to patient care at the UCSDMC via EHRs are happening sooner than at many other medical centers, large and small, and certainly sooner than at many physician practice offices. That is because the UCSDMC begin planning the EpicCare installation 5 years ago, long before the stimulus package passed by Congress last February was conceived. But that package—formally called the American Recovery and Reinvestment Act of 2009 (ARRA)—suddenly opens the door to epic improvements in respiratory care in hospitals and physician offices throughout the country, and not only via EHR systems marketed by Epic. The Certification Commission for Healthcare Information Technology (CCHIT)—which was originally established by the Department of Health and Human Services (HHS)—has accredited EHR systems made by GE Healthcare, Siemens Medical Solutions, Cerner Corp, and a few other vendors as meeting base-level standards for interoperability, security, e-prescribing, and other functions.

The ARRA makes available $19.2 billion in funding ($17.2 billion in direct grants for software, hardware, and installation to physician offices and hospitals plus another $2 billion going to the National Coordinator for Health Information Technology). There is a catch, though: Providers must have a “certified electronic health record (EHR) system” already in place and be a “meaningful user” of such a system. That construct favors hospitals such as the UCSDMC, which will be up and running with EpicCare by 2012. Ford says his department is in the final stages of configuring the EpicCare system for respiratory use. That means defining how the department wants “its” screen to look like, and any “tweaks” to the general medical history software to facilitate the evaluation core therapies in respiratory care, such as aerosol therapy, bronchial hygiene, and ventilator management. Ford and his team are collaborating with the nursing and physician staff to configure the EHR to include procedures such as diagnostic bronchoscopy, ECGs, and activities in pulmonary function and pulmonary rehabilitation, which are services that may not be part of a traditional respiratory care department and require some additional custom configuration of the system.

Respiratory care departments at other hospitals might tweak their systems in slightly different ways; but the ARRA provides a strong incentive for providers who have started the job to finish the job, and for providers who have not even dipped their toes into the EHR waters to get their shoes off in a hurry. Again, to qualify for that money, physicians and hospitals will have to meet certain conditions, chief among them proving they are a “meaningful” user of EHRs and proving “demonstrated performance.” In the case of physician offices, that means e-prescribing at a minimum. The HHS will define the exact list of preconditions physicians and hospitals will have to meet in a rulemaking conducted this year.

Physician offices are eligible for incentives for 5 years, with the total amount dependent on which year they first became compliant with certain standards. If that first year is 2011 or 2012, they would get $44,000 over 5 years. Total payments would be $3,000 less if implementation occurred between 2013 and 2015. Physician offices that fail to meet standards by 2015 would see their Medicare fees reduced that year by 1%, an additional 1% in 2016, and an additional 1% in 2017, with that 97% number coming into play for each year beyond 2017. Hospital-based physicians are not eligible for Medicare health information technology (HIT) incentive payments.

The ARRA incentives for hospitals are a bit more complicated; they are subject to a formula that takes into account certain Medicare and Medicaid payments a hospital currently receives. There is a base amount of $2 million in the first year, which would probably be adjusted upward some hundreds of thousands (but not millions) based on the formula. Payments to an early adopter (in 2012) would decrease over 4 years, and the hospital might get $5 million to $6 million total over that 4-year period. Later adopters would get less. Hospital incentive payments are available only to Inpatient Prospective Payment System (IPPS) hospitals and Critical Access Hospitals (CAH)—the law excludes psychiatric, rehabilitation, cancer, children’s, and long-term acute care hospitals. Acute care hospitals can qualify for Medicaid incentive payments either by having at least 10% of its total inpatient volume attributable to Medicaid patients or by being a children’s hospital.

There are penalties, too, for hospitals that fail to adopt HIT systems. Beginning in FFY 2015, one quarter of the applicable hospital market basket update will be reduced to zero for hospitals failing to meet certain quality reporting requirements.

How Does It Work?

Some providers have been hesitant to commit capital to EHRs, even if they have the funds and expect to be reimbursed out of ARRA funds, because of a fear that the technology is not mature. The CCHIT has been certifying full-blown EHR systems based on standards approved by a second, HHS-endorsed committee: the Healthcare Information Technology Standards Panel (HITSP). The certification of stand-alone e-prescribing systems has been the province of Surescripts, the company that operates the Pharmacy Health Information Exchange, an electronic network that connects doctors and pharmacies to enable the electronic exchange of prescription information.. Users have criticized both CCHIT and Surescripts over their high certification charges, which have forced some vendors to limit the reach of their technology. In addition, CCHIT has been viewed to some extent as a vendor-captive organization, averse to insisting on interoperability. Neither it nor Surescripts, in any case, could be viewed as impartial, third-party certifying organizations.

Greg Downey, executive vice president of academic affairs for National Jewish Health (NJH), Denver, the top-rated respiratory hospital in the United States for 11 years by U.S. News & World Report, says NJH has completed phase 1 of its EHR implementation, which began over a year and a half ago. This first phase, costing about $3 million, represents approximately 60% completion of the anticipated implementation. Phase 2 has run aground on software problems, which the vendor is having trouble fixing, however. “We are having system instability and crashes and problems you can’t work around when doing structured notes and electronic prescription ordering,” Downey explains. Phase 2 is supposed to allow health care providers at NJH to order tests electronically, order inpatient prescriptions and transmit them electronically to pharmacies, and, one hopes, provide a way for physicians to write bedside notes into the system in such as way that those test documents can later be subject to searches. “It is one of the great lies that these off-the-shelf EHR software programs work in all institutions and interface with all the other systems from which data must be gathered,” he fumes. “None of those can be guaranteed.” This is a problem with all of the major software packages currently available.

Ongoing Concerns

Even if and when phase 2 is completed to NJH’s satisfaction, its system will be limited. For example, the EHR software cannot interface easily with the dictation system software that the NJH physicians use when entering patient notes. Initially, there were problems interfacing with the radiology (imaging PACS) software used by the NJH radiology department. Perhaps most important, in its current state, NJH cannot easily share a patient’s records with another hospital in Colorado or elsewhere because of lack of vendor interoperability. “Someone needs to hold these vendors’ feet to the fire,” Downey states. “There is no incentive, and, in fact, there is every disincentive, for them to make it easy for an institution like ours, [which] is dissatisfied with an implementation, to get out and use another vendor, because it is so painful to start from scratch again.”

Those types of criticisms led Congress to include a section in the ARRA on standards and certification aimed at injecting independence and interoperability into the certification process. The bill requires the HHS to set up both HIT policy and standards committees based on selections made by the Government Accountability Office (GAO). The GAO named the first 13 members of the policy committee in early April, and the White House can add other names. The members of the standards committee have not been named yet, but Congress specified a much broader membership of these two committees—the idea was to get beyond the insularity of the CCHIT—that will make recommendations to new HHS Secretary Kathleen Sebelius, who is required under the ARRA to adopt an initial set of HIT standards and certification procedures by December 31, 2009. The ARRA is silent on how detailed or far-reaching those new HHS standards should be, however.

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Even if Sebelius endorses the HITSP standards and the CCHIT certification process at the end of 2009, that will not quiet the concerns of either physicians or hospitals. For example, CCHIT’s certification of the e-prescribing component of EHR systems (again, CCHIT has not certified stand-alone e-prescribing systems, which would be cheaper, certainly for physician offices, than full-blown EHR systems) is based on a standard established by Medicare (not HITSP) for Part D drug plans. The latest version of that e-prescribing standard became effective in April 2009. It omits three standards Medicare pilot tested in 2006 but found wanting. Probably the most significant one is the standard for RxNorm drug nomenclature, developed and maintained by the National Library of Medicine.

“There are a lot of people on the RxNorm bandwagon,” acknowledges Kevin Hutchinson, president and chief executive officer of Prematics Inc—a software vendor—and founding CEO of Surescripts.

Beyond cost and immature standards, another factor standing in the way of health care providers and EHR adoption has been concern about liability in the event that a patient’s medical history—in particular, information about AIDS, STDs, or even conditions that could affect an employer’s view of an employee’s ability to do a job, such as a heart condition—inadvertently gets into the wrong hands. Of course, there already are some base-level health records privacy requirements established by the Health Insurance Portability and Accountability Act (HIPAA). The ARRA expands some of these requirements. For example, section 14405 of the ARRA expands HIPAA to allow a patient with health insurance to pay for a test with cash and instruct the physician not to report the test results to the patient’s employer or health insurance company. Currently, under HIPAA the physician has no choice. He must report the results. But in the future the physician and the pharmacy will have to be able to segregate in their EHR systems patient information that does not go to the payor. “That complicates things, to be honest,” states Dan Rode, vice president, policy and government relations, American Health Information Management Association, who notes that this provision is one of many that will be up for grabs during the HHS rulemaking process, which will unfold this year.

Steve Barlas is a contributing writer for RT. For further information, contact [email protected]