Wednesday, November 20, 2013

Fine Tuning the National Healthcare IT Timeline

I've recently written about and the lesson that going live too soon creates a very unpleasant memory.

As I work with healthcare leaders in Boston, in New England, and throughout the country, I'm seeing signs that well resourced medical centers will struggle with Meaningful Use stage 2 attestation, ICD-10 go live, HIPAA Omnibus Rule readiness, and Accountable Care Act implementation, all of which have 2013-2014 deadlines.

People are working hard.   Priority setting is appropriate.   Funding is available.

The problem is that the scope is too big and the timeline is too short.

What are the risks?

Because of the complexity of the Meaningful Use stage 2 certification process, many stage 1 certified products have not yet been certified for stage 2.   Those that are stage 2 certified have only been recently introduced into the marketplace, making upgrades, training, testing, and full implementation before July 1, 2014 (the beginning of the last reporting period for hospitals which attested to stage 1 in 2011 and 2012) very challenging.   I believe that we could see hundreds of hospitals fail to attest to Meaningful Use stage 2 by the current deadline, despite their best efforts.

We learned from that end to end testing with a full user load and complete data set is important to validate the robustness of an application.   ICD-10 go live for every provider and most payers (other than Workman's Comp) is 11 months away.    Does CMS have time for a full end to end test of all functionality with its trading partners?   I am concerned that not enough time is available.    Will most payers and providers be ready to process transactions on October 1, 2014?  Maybe.   Will new documentation systems, clinical documentation improvement applications, and computer assisted coding to ensure auditable linkage between the clinical record and the highly granular ICD-10 billing data be in place?  Doubtful.    Will RAC audits discover that not enough time was available for training, education, testing, innovation, and workflow redesign?  Certainly.    The risk of a premature ICD-10 go live will be the disruption of the entire healthcare revenue cycle in the US.   The consequences of a delay in enforcing ICD-10 use are minimal.

ONC federal advisory committees are taking testimony from multiple stakeholders regarding the technology and policy readiness of provisions in the HIPAA Omnibus rule such as the Accounting of Disclosures and private pay redaction requirements.    It's very clear that more time and more research is needed before these elements of the law can be enforced.

The Affordable Care Act has many provisions including a move from fee for service to reimbursement based on quality. Quality measures were to be automatically submitted using the QRDA standard.  On November 5, CMS backtracked and announced that they would not accept the QRDA formats and all reporting for January 2014 would revert back to a manual web upload process called GPRO.   It is clear that CMS is not ready to move forward with ACA implementation on the original planned timelines.

So what should we do to fine tune the national healthcare IT timeline?

Meaningful Use Stage 2 attestation timelines should be extended by 6 months to enable recently certified products to be fully implemented in a safe and thoughtful way.    90 day reporting periods for hospitals begin October 1, 2013 and for eligible professionals begin on January 1, 2014.  Attestation must be completed within one year.  Extending attestation to 18 months will give us time to implement new software upgrades properly.

ICD-10 enforcement deadlines should be extended by 6 months to enable additional testing and workflow redesign.  The October 1, 2014 deadline may work for some providers and payers. Transaction flow can begin if systems are functional.   However, a 6 month extension will enable providers and payers to revise and improve systems before a mandatory full cutover.   We need to do this to avoid another situation.

The Accounting of Disclosures and private pay redaction aspects of the HIPAA Omnibus rule should be delayed until pilot implementations can be studied and lessons learned broadly shared, likely a year.

Affordable Care Act implementation should await for maturity in the tools needed to support care management and quality reporting, likely another year.

All of these projects can be done and are reasonable components of national efforts to improve quality, safety, and efficiency.

However, the well meaning people who devised the policy principles did not take into account the operational requirements to do all this work simultaneously.   We should keep moving forward on these goals, but need to adjust the pace.    We all want to finish the race and not collapse before the finish line.


Joe Stewart said...

As a senior manager in a vendor providing software components that fill the white space among the many systems involved in both clinical and revenue cycle operations, I know that all (not just some, all) of my healthcare customers have gaps in core functionality relating to ICD10 and Meaningful Use Stage II - particularly from the testing point of view.

I'm in agreement on your proposed 6 month delay for ICD10. For Meaningful Use attestation, I'd recommend a longer delay, even a significant overlap across Stages II and III.

These recommendations are NOT a step back from the achieving the goals - rather an acknowledgement of the state of IT in Healthcare generally. There's an IT adoption curve that industries go through (e.g. Banking then Insurance then Manufacturing...) which takes time - we as a nation need to accept it, incorporate it into our planning and move ahead.

Medical Quack said...

You are right on here and yes people are "well meaning" and are not some kind of "underground force" if you read the news, politics will almost have you believing such:)

Sad on Healthcare.Gov as yesterday it was revealed that the transaction modules are not even built, so I said they did an "Allscripts" other works the same likeness of not having their code done and it was enough to get a CEO fired as you know, there's no stretching the truth with computer code and technologies:)

People expect a law to remain "static" while the IT infrastructures of running the ACA change by the minute so it's difficult and perhaps we are being forced to really start thinking about digitally centric laws. I keep promoting the Sunshine Foundation project of "restoring the Office of Technology Assessment Agency" as a tool for Congress that they used to have. With as complex as things are today, they need it worse than ever. I watched the Congressman about drop his jaw to the floor yesterday when CMS said the transactions portions of the website were not even started.

We all know the project that was this massive did not allow for time to write code from the ground up and big decision errors there in thinking that could be done and you know that better than anyone with the development of your own software programs by all means:) I keep asking about the turnkey state exchange platforms from Oracle and Microsoft..were they good, did anyone look at them..again curious as to if anyone looked as there would be some time saved writing integration code.

Yes indeed, both the government and consumers are getting a real cold hard lesson on the complexities of IT Infrastructures we live with today for sure, and it's not all nice:) I said that a short while back and I agree 100% that you do not put a project out there before it's time and I even said they could have marketed it as "betas" with more focus on the manual application methodologies until the site was performing better.

Adrian Gropper said...

When it comes to slowing things down, it's important to separate EHR functionality from EHR interfaces. Because the dominant EHR business model is "vendor lock-in" the only realistic way to accelerate both functionality and interoperability is by prioritizing free interfaces. Without the risk of competition from Web services and apps, EHR satisfaction and interoperability will continue to disappoint.

Ahier said...

John, I wholeheartedly agree with your proposals!

Roy B said...

Whole hearted agreement; however, the timeline extension of 12 months would be more appropriate or possibly stager for larger vs smaller facilities. Larger, well resourced facilities (money, personnel, legal departments, large IT departments, foundation support etc... ) may indeed make the 6 month and possibly the current dates. However, a small critical access hospital with one person assigned to HIPAA, EHR, MU, UR, etc.. and still responsible to meet all requirements larger facilities are required is a difficult task at best. I am not suggesting exempting organizations. I am suggesting additional time and possibly even collaboration with larger hospitals to help meet the requirements.

Anonymous said...

Interesting blog for health care. Actually google made searching of information easy on any topic. Well keep it up and post more interesting blogs.

Anonymous said...

Well said as always John. There are a multitude of documents now surfacing that provide conflicting requirements from final rules and specifications. This is creating a frenzy of questions, reevaluations and just panic across hospitals, providers and vendors. Interpretations are as always wide open. You will get various answers to the same questions. Standards for measures are not clear and completely dilute what we are trying to accomplish. Every process, measure and function needs to be reversed engineered to consider audits of unkown parameters. And to think the reporting period is underway. Most need the funds to keep doors open. Another health care mess.