Phasers on Stun — The Roll-Out of Meaningful Use

(Chart Data above from HIMSS Analytics, 2008.) May 18th has come and gone. It had been the first hopeful date to start the public comment period on the government’s proposed criteria to get paid under the ARRA-HITECH incentive legislation. Despite not hitting this mid-year date, we are gaining clarity, as has been evident in the meetings of the last few days. At least for the inpatient world, a phased approach to getting to CPOE is not an option; it’s a necessity. The graphic above came from a presentation I gave Friday at Washington DC’s HealthTechNet. The original presentations (mine and Joyce Hunter’s) can be found here. What it says, simply, is that given where the hospitals are in this country in terms of the stages shown, the majority (62.8%) are at stage 2 or lower. It’s virtually impossible given what we know about HCIT, for them to get to stage four by 2011. If the goal of the incentive is to give everyone (or at least almost everyone) a bonus incentive for investing in EMRs, a simple, single criteria for 2011 is not logically possible. That leaves us with a few choices: 1) The HIMSS proposal explicitly lays out phases that would apply to all hospitals. That has the fairness virtue that the same criteria would apply equally to all hospitals. It would reward those institutions that are well on their way. But, for them, their prior investments would be effectively discounted because their competitors (this is the US free-market healthcare economics model) would have more time to catch up. This reduces their earned competitive advantage. 2) Another approach would be to set a moderate, stage 4 hurdle for 2011, knowing (again, from the chart above and our knowledge) how long it takes in the best of circumstances to roll-out HCIT. That would allow 37.2% of the hospitals to get to Stage 4 or beyond. The efficient next group, maybe the 33.2% currently in Stage 2 to catch up by 2012, with only a modest reduction in earnable incentives. 3) The third approach would be more complicated, essentially rewarding year-over-year progress directly, rather than having one finish line. Progress here could be stratified to take into account relative hardships, related to populations served, etc. This would be the “no hospital left behind” approach in terms of immediate opportunity to earn incentive dollars. Although more complicated, there are precedents in CMS incentive programs to reward progress, rather than simply a top percentage group. Of course, that all pre-supposes that CPOE is the absolute, near-term requirement. Suppose, on the other hand, we listened in carefully to Governer Mark R. Warner’s HIT conference on May 18th. Here, Dr David Bluementhal, Dr Robert Wah, Tony Trenkle and Dave Roberts gave really great presentations. A recurring theme was there were three “I”s: Infrastructure, Information, and Incentives, essentially stacked sequentially to get the improvements EMRs can bring to our healthcare system. If we liberally equate information with improved effectiveness through decision support (with or without immediate CPOE), we rediscover the Vowels of Healthcare Improvement model I shared in March. The Infrastructure and Information goals are substantially similar to Stage 3 of the adoption model, and if achieved with certified products, would represent substantial new work for the vast majority of hospitals in calendar or fiscal year 2011. It seems to me that the public is already commenting thoughtfully on issues and the options out there. Maybe we haven’t actually missed May 18th after all!