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June 2009

High Demand Persists for Chief Medical Information Officer (CMIO) and Health IT Physician Champion Roles

Physicians with health information technology (HIT) implementation experience are in high demand for a variety of roles in organizations that are implementing clinical IT systems such as electronic medical records (EMRs).  The roles and responsibilities of these physicians has been evolving and growing.  IT physicians in the early 1970s typically served as clinical "subject matter experts" to ensure that clinician's needs were identified and met by IT projects.  In the 1990s the need for IT physicians increased as more hospitals implemented clinical IT systems.  Throughout the 1990s a series of studies on the high prevalence of medication errors and the ability of HIT tools to reduce these errors culminated in the 1999 Institute of Medicine report, "To Err is Human".  This led to external pressure on hospitals to more aggressively pursue implementations of more advanced clinical technology tools such as electronic medication administration records and computerized physician order entry (CPOE).  Some of these implementations failed and others experienced sub-optimal results.  Strong clinical leadership, management and oversight at the executive level became recognized as a key factors in successful implementations.  The project-oriented, physician liaison role was still needed but no longer sufficient.  A new generation of IT physician leaders, the Chief Medical Information Officers (CMIOs), have been added to a majority of hospital executive staffs to meet these leadership needs.    

The increase in complexity of EMR implementations is due to the development of HIT products that provide more advanced functionalities and more configuration options for users to evaluate and implement.  This increase in the number of functionalities available creates more work to do during the design, build and testing of the systems. More importantly, the advanced clinical IT tools such as CPOE impact a greater number of direct clinical care processes including the daily work flows for patients, nurses and doctors.  These changes to processes and work flows cross over cultural boundaries in a way that organizations have not previously experienced.  The transformational effort needed to overcome these cultural boundaries requires strong clinical leadership, communication skill, consensus-building skill, political maneuverability, strategic thinking, adaptablility, strong interpersonal skills and sensitivity to the organization's nuances and uniqueness. These skills describe some of the ideal characteristics of today's CMIOs.

It is important to reiterate that physician champions who are clinical "subject matter experts" remain in high demand for clinical implementations in addition to the CMIO.  These physicians essentially become part of an informatics team with the CMIO.  Even in small organizations it is obviously not possible for the CMIO to be the subject matter expert for every clinician for every clinical project. The CMIO can, however, be the catalyst to get the right amount of clinician participation with the right clinical expertise into clinical IT projects. The CMIO can facilitate the redesign of hospital committee structures and roles to ensure ongoing support and governance of a new EMR.  To be effective, then, the experienced CMIO manages time by differentiating between situations that require their expertise through close, detailed involvement from other situations that are best managed as a facilitator, educator or mentor. 

The value of a multidisciplinary informatics team with physician, nursing and other clinical liaison members is recognized by organizations.  Organizations today should therefore consider planning for a multidisciplinary informatics team not just for their initial major clinical implementations, but also for ongoing optimization and support of these expensive systems.  This group is the source for clinical "subject matter expertise" during IT implementations.  After the implementation this group of clinicians becomes an invaluable resource for the continual optimization and support of clinical technologies.  Some members, such as the physician champions, will not need to spend as much time with the informatics team post-implementation, but their experience and expertise will be tapped into.  Some hospitals have decided to attract physicians to this role by creating an inpatient Medical Director for the EMR / Computerized Physician Order Entry (CPOE) and an outpatient Medical Director of Ambulatory EMRs for their physician offices.  Some are full-time positions and others are part-time, dependent on the size of the organization, and they work closely with or report to the CMIO.   

The early physician IT champion role of the 1970s evolved into an executive level CMIO role as clinical technologies became more advanced, more costly and more complex to implement.  CMIO positions have subsequently become common within hospital organizations.  Physician champions, however, also remain in demand as clinical "subject matter experts" for their clinical IT systems.  As organizations continue to implement, upgrade, optimize and support their  expensive clinical IT systems, CMIOs and clinical IT liaisons including physicians, nurses, lab technicians and pharmacists will remain in high demand.   

drmattmurray


Comments on ONC's Preliminary Definition of "Meaningful Use"

On June 16th the Office of the National Coordinator for Health Information Technology (ONC)  announced a 10-day period for comments on their preliminary definition of "Meaningful Use".  This definition is important to clinicians and hospitals who could qualify for incentive funds if they are "meaningful users" of health information technology (HIT).  The federal stimulus program, through the American Recovery and Reinvestment Act (ARRA), includes $20 billion for these incentive funds.  ONC has posted on their website a preliminary definition in the form of a Meaningful Use Matrix document.  Comments on this preliminary definition can be sent to ONC through their website until June 26th at 5:00pm.  The rules for incentive payment qualification that the Department of Health and Human Services (HHS) will announce  later this year will be guided by the recommendations made by ONC.  

Participating with two organizations who are preparing to submit comments to ONC has clarified for me that the most important aspect of this matrix is the "Measures" column.  The "Measures" column lists the detail for what physicians and hospitals will be expected to do in order to be qualified for incentive payments as meaningful users.  Assessments and comments should therefore focus on the "Measures" in the matrix.  It appears that the Objectives column includes things that are expected to occur as providers achieve the measures, but are not specifically required for reimbursement. This should, however, be further clarified by ONC.

If you are interested in submitting comments to ONC or you are just interested in seeing more details, please click here to see a list of my comments on the preliminary definition of "meaningful use".  One thought that struck me as I worked on this is that the incentive payment program will create new opportunities for vendors to provide "services" to physicians by streamlining the effort that will be required to receive incentive payments over the next 6 years.  

drmattmurray


Meandering Means to Make Meaning of "Meaningful Use"

Unless one is closely following the day-to-day activities of the government as it relates to the health information technology (HIT) world, the importance of "meaningful use" and how it is coming to be defined is hardly stimulating. Acronyms make matters worse. Just when common information technology (IT) acronyms, such as "IT", are becoming increasingly familiar, unfamiliar phrases like "meaningful use" are turning into "MU". As a consequence, the average person attempting to follow these activities will quickly feel as though overdosed on a CNS depressant...oh, and that reminds me, medical acronyms like CNS (central nervous system) are also being thrown into the mix. So in today's blog entry let's see if an explanation of the importance, timeline and participation in the current "meaningful use" activities can be simplified. Here we go!

Importance: The American Recovery and Reinvestment Act (ARRA) authorizes the Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS) to provide incentive payments to physician and hospital providers who are "meaningful users" of "certified" electronic health records (EHRs). These incentive payments begin in 2011 and gradually phase down. Starting in 2015, providers are expected to have adopted and be actively utilizing a "certified" EHR in compliance with the "meaningful use" definition or they will be subject to financial penalties under Medicare and Medicaid. Who gets part of the $20 billion of incentive payments is dependent on how  "meaningful use" and "certification" are defined.  ARRA created two advisory committees, the HIT Policy Committee and the HIT Standards Committee, to make recommendations to HHS on the incentive payment roadmap. Both Committees report to the Office of the National Health IT Coordinator (ONC) which operates under HHS and is led by the "health IT czar" David Blumenthal, MD. How "meaningful use" is described will essentially set the priorities for the Standards Committee and be a major influence on how "certification" is defined.  The Policy Committee is developing key objectives that they want "meaningful use" to achieve and establishing metrics for each of those objectives.  These specific objectives and measures will describe what physicians and hospitals will need to do in order to qualify for part of the $20 billion incentive payments.  This has caught the attention of many.

Timeline: The HIT Policy Committee formed a Meaningful Use Workgroup earlier this year to begin hammering out a proposed definition of "meaningful use." The HIT Policy Committee held their first meeting this week on Tuesday, June 16 and discussed the draft proposals from the Workgroup. The Policy Committee will meet again on July 16 to discuss revisions that the Meaningful Use Workgroup makes to their proposals based on this week's meeting and public comments. HHS will consider the recommendations provided by these groups and is expected to issue rules by the end of this year.  This is by necessity an extremely short timeline considering the complexity of EHRs and other health IT tools, the length of time it takes to successfully implement these tools and the fact that "meaningful use" requirements are attached to the 2011 incentive payments.   

Participation: Since the HIT Policy Committee is operating under the transparency of the Federal Advisory Act (FACA), it makes available a public transcript of the June 16 meeting on the ONC website and has provided for a 10-day period of public comment on the proposals. For those interested, the period open for public comment on the initial draft ends on June 26. Included in the public transcript of the June 16 meeting is a draft of the Meaningful Use Matrix which appears to be the core tool that will be used to define "meaningful use". It is a matrix design because the definition of meaningful use is phased in, becoming more challenging in each of the 5 years. The focus of comments to ONC right now should be on the specific objectives and measures proposed in this matrix since incentive payments will be based on these. It has not been decided whether another comment period will be offered after the July 16 presentation.

The Meaningful Use Matrix can be summarized at a very high level by this slide from the Workgroup's presentation.  It shows that incentive payments will begin in 2011 with "Pay-For-Reporting", phase into "Pay-For-Using" and mature into "Pay-for-Outcomes" by 2015.  In other words, initially the incentive is to get providers using EHR tools to capture certain health data and be capable of reporting on that data.  The next phase is to incenticize providers to actually use IT tools and health data during patient encounters.  The last phase is to stimulate providers to demonstrate improvements in patient outcomes through the use of the IT tools.  

So, there above lies the simplified explanation of the importance of the current "meaningful use" activities. For insomniacs, "take" two readings of this blog for the full CNS depressant effect! 

drmattmurray

 


The Conundrum of Physician Adoption of HIT, Health Information Exchanges (HIEs) and Stimulus Funding

Despite an increasing amount of literature and anecdotal evidence that electronic medical records (EMRs) improve quality of care, many clinicians harbor lingering doubts about the value they will gain by implementing an ambulatory EMR in their office.  The concern is not without merit.  EMRs today do provide value to the physician by providing real-time access to legible patient data, clinical decision support tools and reporting capabilities; with attentiveness to work flow redesign during implementation this value can be gained without unacceptable impact on physician time.  However, it is dissappointing to physicians that there is a significant gap between the value EMRs bring today and the largely untapped potential value of connecting EMRs in order to confidentially share patient data across the community.  Current EMR technology makes possible physician access to critical patient data in disparate EMRs entered by other community providers, hospitals, labs, radiology departments, emergency rooms and other credible sources. The technology infrastructure that allows this exchange of patient data between EMRs is called a health information exchange (HIE).  The value of ambulatory EMRs increases significantly when connected to an HIE infrastructure that enables access to and display of exchanged community-wide patient data whenever, wherever the physician needs it for patient care.   

This additional value of ambulatory EMRs cannot be fully realized until a critical mass of providers in a community are using EMRs and the community has the HIE infrastructure available to connect EMRs. For example, if 99% of medical records are paper and only 1% are entered electronically across a community, the value to a physician for connecting with the HIE would be minimal.  The conundrum is that the business model to allow HIEs to thrive is also dependent on a critical mass of providers using EMRs because EMRs provide the HIE with its commodity which is patient data.  HIEs in communities with low EMR usage therefore have difficulty sustaining their existence for financial reasons.  

HIE infrastructure is growing but is still not prevalent in our communities; also, less than 10% of U.S. physicians are using a fully functional EMR according to the New England Journal of Medicine (NEJM, Volume 359:50-60, July 3, 2008, No. 1).This conundrum is addressed by the Health Information Technology for Economic and Clinical Health Act of 2009 (HITECH) portion of the federal economic stimulus program.  HITECH provides not only incentive payments to physicians who adopt EMRs, but also funding opportunities for the development of HIE infrastructure, policies/regulations for privacy/security and "Regional Centers" to help coordinate this effort.  The purpose is to not only stimulate enough momentum for physician adoption of EMRs to reach a critical mass, but also to concurrently stimulate the development of more robust community HIE infrastructure.  The conundrum requires a concurrent effort so that, as doctors adopt EMRs, new HIE infrastructure adds value by enabling physicians to access a comprehensive set of patient data from the community in a practical, useful and confidential manner.  

drmattmurray


AMA Meeting Next Week to Discuss ARRA and Health Information Exchanges (HIEs); Physicians Need to Maintain Ownership of Patient Health Information

The American Medical Association (AMA) is meeting in Chicago next week to discuss President Obama's federal econonomic stimulus package (ARRA) as it relates to the healthcare industry.  The Department of Human Services will have representatives present.  The Texas Medical Association and other state medical societies will concurrently participate in peer-to-peer meetings to discuss the role that state medical societies can and should have regarding the health information technology incentives and the health information exchange (HIE) infrastructure.  In order for physicians to gain value from implementing ambulatory EMRs, there must be an infrastructure (and policies/procedures) in place that allows patient information to be accessible whenever and wherever it is needed.  This infrastructure will succeed only if it garners the public's trust that the privacy of their health information will be maintained.  It is my belief that the public is far more likely to trust their local doctor with private health information than they will any government entity or other anonymous public-private HIE entity.  Local doctors typically are members of their local county medical society, and these county medical societies roll up to the state's medical association, such as the Texas Medical Assoication.  One strategy is to allow local physicians to maintain "ownership" of private health data by having their county medical society establish a community data repository.  The physician's medical society would become "the owner" of the data, protecting the patient's privacy while providing appropriate access to providers who need the data to provide high quality care during patient encounters.   This idea has surfaced in the state medical association arena.  As digitized patient health information becomes more prevalent and therefore more valuable to exchange, the financial difficulties HIEs encounter today will wane.  At that point garnering and maintaining public trust will become a primary challenge for HIE sustainability.  Leaving ownership of private health information data repositories to the providers is one way to achieve public trust.  It will be interesting to follow up with state medical associations following next week's meetings concerning the state and national HIE infrastructure strategies.  

drmattmurray


Stimulus Funds Include Physician Incentives (and Penalties) to Encourage EMR Adoption

The Health Information Technology for Economic and Clinical Health Act (HITECH) is part of the Americian Recovery and Reinvestment Act (ARRA) of 2009 and provides around $19 billion for health information exchange infrastructure including incentive payments to physicians adopting EHRs and other health information technologies. Physician reimbursement penalites for not using health information technology (HIT) begin in 2015 with a 1% reduction in Medicare and Medicaid reimbursement which increases to 3% over 3 years.  The following chart is an example of the incentive payment schedule for eligible physicians who care for Medicare patients:

First Payment Year

2011

2012

2013

2014

2015

2016

Maximum Potential

2011

$18,000

$12,000

$8,000

$4,000

$2,000

-

$44,000

2012

 

$18,000

$12,000

$8,000

$4,000

$2,000

$44,000

2013

 

 

$15,000

$12,000

$8,000

$4,000

$39,000

2014

 

 

 

$12,000

$8,000

$4,000

$24,000

To be eligible for incentive payments, physicians must:

  1. Meet minimum threshhold Medicare or Medicaid payor mixes.  For example, non-hospital-based pediatricians with a 20% Medicaid payor mix will be eligible for up to $42,500, and those with 30% a Medicaid mix will be eligible for $63,750. 
  2. Demonstrate "meaningful use" of certified EHR technology (will include e-prescribing)
  3. Submit clinical quality measures as selected by the Health and Human Services (HHS) Secretary (similar to the PQRI  or pay-for-performance programs). 
  4. Be able to connect to electronic exchanges of health information

The American Medical Association's (AMA) Summary provides additional information on the incentive payments.  Important details and definitions, however, are yet to be determined and will be released by HHS later this year. It is important for physicians to ensure that their interests are represented as the details are discussed and determined. For example, a hot item of current discussions is the definition of "meaningful use".  The AMA and state medical societies are among the physician voices that are active in a national dialogue defining this term.  Other unclear items include how payor mix will be determined, what constitutes a certified EHR, what the required clinical quality measures will be, how physicians will submit quality measures and what type of electronic exchanges of health information are expected to be connected to. 

As an advocate for the use of clinical technologies to improve the quality of care, I am excited about the potential for the incentive program to stimulate a more rapid adoption of EHRs.  However, I am wary about the undetermined details and definitions of the incentive program.  Physicians will want to see the government avoid creating an incentive program that is heavy on more administrative controls over clinical decision-making and on demanding untenable changes to the busy physician's day (such as complex, time-consuming reporting requirements).  I am also concerned about physicians feeling rushed into EHR implementations that, due to time constraints, might fail to be attentive to the redesign of physician work flow that is needed for successful implementations.  Because of the potential for these negative impacts, I implore physicians to ensure that their professional associations and organizations are engaged in the ongoing national health information technology dialogue and to share your ideas/concerns with them. 

drmattmurray