Tip:
Highlight text to annotate it
X
Rural Hospitals Achieving Success An Amazing Journey
MALE SPEAKER: Thank you for joining Rural Hospitals Achieving Success -- An Amazing
Journey. Before we get started, Iíd like to first give our instructor Marcia Cheadle
in -- a chance to introduce herself. So Marcia? MARCIA CHEADLE: Good morning. My name is Marcia
Cheadle. Iím the Director of Clinical Information Systems at Inland Northwest Health Services,
and I have the pleasure of working with a number of hospitals across the United States
implementing advanced clinical technologies in an effort to a large degree to meet the
governmentís ARRA [spelled phonetically] or meaningful use stage one initiative. Over
the past several years Iíve worked with probably over 20 hospitals, primarily critical access
facilities, on those successful journeys and todayís presentation will really provide
all of you at a high level of some of the strategies that weíve been successful with
in working with these particular hospitals. So what [spelled phonetically] -- Iíll review
todayís agenda really will look at, again, how weíve worked particularly with our CAH
[spelled phonetically] facilities to successfully achieve stage one meaningful use instead of
moving many of them onto the stage two strategies and looking at that program for next year.
Some practical applications that weíve deployed and executed on at the critical access programs
for leveraging their talents to achieve stage one and then really how weíve worked with
them to design a program that prepared them more for the stage two platform.
Todayís program will talk kind of on an overview level of four particular areas. One is looking
at some of the barriers that we found unique to the critical access area, really looking
at preparing and planning for that, looking at regulatory programs in general, and what
is really the vision of the federal government. Weíll then look at some -- or talk about
some practical applications and how do you really execute on a plan for moving your programs
to meaningful use, and then finally looking at what we call the next race -- ensuring
that your programs in your communities are leveraging the health care technologies that
were deployed for stage one to meet the stage two and subsequent regulations by the federal
government. So again, as I indicated, we worked with a
number of hospitals beginning this journey in í09. These are independent facilities.
They are not owned or operated by a large corporation, to a large degree anyway. And
in early 2010 we did an evaluation of the sites that we particularly were working with
very closely and selected 12 of the 20 to move forward with stage one and we worked
with their leadership to see if that was something that those hospitals were interested in. So
in 2011, we had nine critical access hospitals and three larger entities hospitals. A test
for meaning see [spelled phonetically] of stage one, both Medicare and Medicaid funding
-- instead of funding programs [spelled phonetically], and then in 2012, we then worked with eight
additional critical access hospitals, again, that with the same sort of methodology, the
same strategy that weíre going to talk about today on moving them successfully forward
with stage one programs, and now weíre working with two critical access hospitals and other
larger hospitals on meeting stage one in the 2013 year, and I also work with a lot of hospitals
across the nation sort of ad hoc. So in our service area, we do both hosted and non-hosted
strategies for our hospitals so that the experiences all [spelled phonetically] share will be from
both of those realms. In addition, another metrics of electronic
medical record adoption is the HIMSS EMRAM model, and we have found quite a correlation
between stage one criteria by the federal government and the HIMSS model for electronic
adaptation and they [spelled phonetically] have positioned many of our hospitals -- six
as of now. I think thereís actually nine right now for stage six, and I just recently
had the call with HIMSS in one of our critical access hospitals on stage seven application
and look for that site visit in June of this year.
So over the next about 40 minutes, weíre going to quickly talk about kind of how we
are approaching meaningful use and for the first three slides, weíre going to go over
some of those barriers and how you can kind of look how you are going to best prepare
a plan for engaging on the meaningful use journey with kind of whatís coming out from
the federal government. And the first slide -- really, I talk about how youíre going
to prepare from a language perspective. The number of acronyms and changes that are coming
out in terms of language definitions by the federal government is astounding and really
overwhelming to many of our critical access hospitals, and what we encourage you to do
is begin to get yourselves a book to define what these particular acronyms mean and then
more yet how they apply to your program in your community and how youíre going to interweave
your strategies with sort of what the vision of federal government is.
So for example, the first one, HIE -- Health Information Exchange. What does that mean
for your organization, what does that mean for your community? Thereís Health Information
Exchanges in states and regions and thereís a lot of ways to interpret that for your hospital
and itís important for you to garner what you want to achieve from a Health Information
Exchange for your population and your providers. Interoperability, standards -- these are all
words coming out from the federal government, all with very strong definitions and itís
really imperative that as we begin to dialogue with other entity or state vendors, that kind
of thing, that we really understand what these words mean because a lot of people are using
them and they may sort of allude to different definitions. And these are unique definitions
as they relate to the meaningful use platform. Next thing that we see is sitting with our
hospitals to look at what resources do you have? Where do you sit in terms of positioning
your organization to make meaningful use? And what are some of the unique challenges
that you have? It may be the same in certain cause [spelled phonetically] or it may not
be the same, but things like personnel. What personnel do you have available to work on
meaningful use? When I started in í09, we took three people to move just to meaningful
use. Thatís all they do. We now have five people on that particular platform and itís
important to understand do you have that resource or not, and if not, thatís okay. Thereís
a lot of resources available that you can tap into, but kind of doing a current state
of your particular hospital, looking at your solutions, what youíve done creatively in
the past, and how youíve used personnel in those creative solutions. Looking at your
budgets, making sure your CFO has budgets set out to target the meaningful use and capture
those dollars accurately and what youíre doing to obtain meaningful use, both in the
hardware software and then personnel budget-wise. And there, again, are resources available
from a dollarís [spelled phonetically] perspective -- a Medicaid IU funding -- adopt implement
upgrade is a funding source if youíve purchased certified hardware and software, that you
can then use to use that dollars to then further your meaningful use program.
One thing that I really encourage hospitals to do is sit back and look at the expertise
and experiences within their organizations. What typically we see is that the organizations
have done very, very well in developing solutions -- very creative, innovative solutions for
how to get things to work in their organizations, in their hospitals, but that may not be the
expertise -- the same expertise required to meet meaningful use. And so we need to understand
if you have that or donít and where weíre going to fill the gaps for those types of
services. ICD-10 -- the reason I put this on here is
ICD-10 is a threat to us, right? For those of us on a meaningful use journey, we have
about 26 projects perhaps running in parallel that all are aligned to hit the meaningful
use time frame. Well, ICD-10 is a government-required program thatís coming in. It has to be in
place by October 1, 2014, and so as you are lying your programs, as youíre lying your
timelines and strategies, you need to have areas in there that you can add other regulatory
programs like ICD-10 and understand how those might be weaved into the current project plans
that youíre doing. So always save room for those -- the next best thing that the governmentís
thrown our way to ensure that we have what we need -- the space and time to meet our
timelines. Certainly the pace is critical. The governmentís defined the time frame,
itís defined the pace, and the payment penalties are coming in 2014 -- or 2015. Sorry, sorry.
Itís 2015. We have payment penalties. So you have plenty of time to hit meaningcy in
stage one and get yourselves on that journey before payment penalties. But you canít spend
a lot of time trying to figure this out, right? Youíve got to start.
And then the thing that weíve seen over the last couple of months in particular and thatís
hit the news is where the programs as we increasingly put data into an electronic platform, these
programs must be available to the clinician. They must be up. They must have the data available
when the clinician needs to care for that patient. So a lot of our hospitals do not
have a strong disaster recovery program or a strong infrastructure for redundant programs.
Even our large organizations not -- havenít necessarily put time in this and itís just
something to consider. Itís not that you have to have it buttoned up by the time we
hit meaningful use, but we need to have it in our -- back of our minds how -- what are
we going to do if our program doesnít stay up, and we really need it to stay up, is weíre
encouraging providers to spend more time in the electronic platforms.
And then the third thing is to educate our folks -- educating them on the rules, on the
goals, on what weíre trying to achieve in meaningful use because again, just like with
the language changes, these rules are here and theyíre very prescriptive. The government
has very, very well-defined program achievements -- what itís looking to get to. So theyíre
in the front [spelled phonetically] of these things called cord [spelled phonetically]
measure -- according [spelled phonetically] to many objective standard and measures, and
for each objective theyíve outlined, they have a standard to meet that objective and
the measure or threshold by which gets you success for that particular stage. One of
the things to keep in mind that as these stage one, stage two, stage three platforms begin
to unveil -- are unveiled by the federal government, they increase the measure. They increase the
threshold of the objective and the standard that we have to meet.
Quality measures I call out because quality measures is being moved out of the platform
of meaningful use as a -- just an overall expectation. The expectation that folks have
at each of their institutions that you will from an aura [spelled phonetically] perspective
-- meaningful use perspective, you will complete the quality measure requirements and submit
that data to the federal government. Now, the problem with quality measures is that
is does not align with the current quality measures that you are submitting to the federal
government, and so you want to be very, very cautious and careful, very deliberate about
what the data is that youíre sending because we donít want conflicting data going to the
federal government in any way ever. So itís sort of aligning the quality programs youíre
doing today, those measures, those metrics, and moving those into the aura of quality
definitions, and when that wonít work, right, when that isnít going to work for us, then
we know what weíre going to do and how weíre going to handle that and how weíre going
to explain that. Other things that are unique in the aura platform
is you include your emergency department or not. You always have to include your in-patient
populations and your observation. Thatís what OBS is -- observation patients, but you
donít have to include the emergency department. And one of the things you want to keep in
mind is in your CAH facilities, particularly some of our smaller CAHs, your inpatient census
is very low, and so if your threshold is 80 percent, you need to pretty well be at 100
percent on adoption in order to be successful with your measure because you donít have
half a patient, right? And so you may need that, what I encourage our CAHs to do is develop
both platforms -- emergency services area and our inpatient areas if you have time,
and then as we get closer to reporting, weíll pick the best dry-zee [spelled phonetically]
for the best numbers for the reporting period. And for the first year first stage when you
only have to be 90 days, right, and so 90 days equals year one. Now a year typically
in most of our minds is 12 months, but for the federal government rule, 90 days is your
first reporting period. Thatís 90 consecutive days of meeting each core and menu objectives
that choose and making sure that you can [spelled phonetically] report on that that they are
meeting threshold the whole time. You cannot be implementing during those 90 days, and
that during those 90 days you are using certified software -- software that has been tested
by federal government certified programs or agreed programs like Drummond [spelled phonetically]
or CPHIP, that you use those vendors and [spelled phonetically] their certified versions to
meet your meaningful use criteria. The other thing thatís unique for hospitals
is the government uses the fiscal year for hospital reporting. So on October 1, the year
changes. So October 1, 2013 will be the 2014 reporting year for meaningful use, and that
issue becomes, when we do a 90 day consecutive reporting, the last day we can start our reporting
for any year would be July 1. Okay? So weíre in April. If you havenít started preparing
for stage one this year and you still want to achieve stage one this year, there are
ways, but itís pretty creative and innovative to get there.
Medicaid AIU funding -- that is a funding source available. Every state has Adopt Implement
Upgrade dollars and you have to just prove that you own the software, that you have licensed
the software, and then you can have potential funding dollars for implementing meaningful
use. The other thing I want to call out is that in the meaningful use rules, they combine
the rules with eligible provider and then your eligible hospitals, right? So the hospital
rules, whether itís PPS or CAH, are very different than the eligible provider rules,
and so you need to make sure when youíre dialoguing the stakeholders and with others
in your organization that everybody knows what year youíre talking about, that youíre
looking to attest, which program youíre talking about, whether itís Eligible Provider or
CAH, and again, what programs, whether youíre going to use your inpatient or whether youíre
going to use your ED as well. Okay. So the next three slides really talk
about why weíre doing this. What is the goal of the federal government? Well, obviously
the goal is to reform the healthcare platform, particularly related to dollops [spelled phonetically].
Itís a payment before model. And one of the best documents Iíve read that relates to
what this vision is is called the PCAST report, and the PCAST report is the presidentís council
of advisors on science and technology and in December of 2010, they published a document
called Realizing the Full Potential of Health Information Technology to Improve Healthcare
for Americans: the Path Forward. And that path forward document really outlines what
the federal government is looking to do over the next five years, all right? And we remember
they published it in 2010, so weíre already in year three. All right, so theyíre looking
for line [spelled phonetically] dollars as it relates to quality outcomes -- demonstrative
quality outcomes for hospitals, and theyíre doing a number of ways -- theyíre looking
at a number of ways to do that. Accountable care organizations is one way that combines
organizations, combines patient populations, and manages dollars against that patient population.
Medical center homes is another model, value-based purchasing -- these are all models of services
that people -- that the government is trialing to see how it can best control the cost of
care. Our role for hospitals is just to begin the journey of meaningful use. Just begin
to enter data in a certified structured manner -- in a certified platform in a coded and
structured manner for that data element -- that critical data element designed for the patient,
right, that you collected on that particular patient to be shared with other clinicians
who care for that patient. So stage two, which begins in 2014, again
which is the October 1, 2013 date. That begins 2014. Year two -- stage two is all about the
data exchange and promoting this coordinated care -- promoting all people who deal with
outpatient, giving them the joy of information, information that you contribute from your
hospitals so that we can have [spelled phonetically] the best overall outcomes for our patients.
And then the stage three, which is coming further yet, is all about then reporting on
those outcomes for target goals and target incentives to reduce overall costs. We will
be looking at the quality reports to understand what community population health needs to
look like and what that should cost. In order to support this vision, the government
came out with a number of objectives, and their objectives are patient safety, right,
privacy and security -- we know that, right, because the HIPPA rules -- the new HIPPA rules
came out in January -- care coordination model -- the care coordination means how we take
data and hospital helps take [spelled phonetically] data and include the patient and all care
practitioners -- care deliverers to do the best treatment and follow the best treatment
plan for that patient to optimize their health. Weíll be looking at overall population and
public health as I described in stage three coming, and then this new issue youíll hear
a lot about this year about patient engagement, family engagement, having the patient in their
record, seeing their record, taking part of their care treatment.
Now, again, what part do we play? What part do we play to support the objectives that
support the overall goal -- the goal of shared data? And all we have to do at our hospitals
is input the data. Weíve got to input the data today. The system, the vendors themselves,
will take care of the mapping, will take care of normalizing that data so that it can report
outbound. You hospitals need to get the data in. You need to identify which data elements
youíre inputting, and again, very prescriptive model by the federal government. You donít
have overall choices, right? You have some choices. But the key with implementing the
data streams is implementing in a way that cle-missions [spelled phonetically] will adopt
-- implementing it in the clinical workflow. We are going to take those data streams from
a software and hardware perspective and map it to the technology standards required for
sharing that information to other sources, to other EMRs, to other hospitals, for outbound
reporting. So this is all the hospital has to do -- our section right there.
Okay. Now the next eight [spelled phonetically] or so slides is going to talk more about -- okay,
how do we get started? What are we going to do? This is not lengthy time, right? This
is just what are we going to sit down and do, and the first thing we have to do is to
educate our leadership -- to establish a leadership team and all hospitals have a leadership program.
They have the C-sweep [spelled phonetically], right? Your CEO, CIO, the CNO -- those people.
Those people we need to teach, we need to educate on meaningful use, on the ARRA program,
and then have some sort of strategy where we report up to them our successes on a bi-weekly
or monthly basis. But these three people can move and can mitigate barriers for us. We
need them on board. And we need the language to be defined the
same. So when weíre talking with them, everybodyís on the same page. We need to do the same with
our clinical team. IT has always been there in hospitals, but in most of our CAH hospitals,
our IT strength has been in network infrastructure and desktop. It is not been in the operations
view of the clinical realm [spelled phonetically]. We have not been key in implementing clinical
systems. So now itís the time where we bring the clinical subject matter experts from the
hospital together with the IT core team -- again, educating them. Educating them on what weíre
trying to do and understand how many clinical implementations we need to engage in at our
hospital to be successful. And the team I want to make sure we do call out as well is
the financial team. This whole program is about registration at a station, having the
budget available to do our programs, so we need to make sure again that our financial
team is aligned with our goals and our strategy for successfully obtaining meaningful use.
Planning -- planning is the key, right? So what -- where are you? What is your current
state? Analyzing your situation at your hospital as it relates to meaningful use and celebrating
your successes, right? Leveraging your successes in the past. Most people have some kind of
electronic platform in their hospital. Some -- theyíre gathering some kind of data. Right
-- most hospitals. So itís really been taking a look at that, understanding what more we
have to do, making sure we understand both from a software and a hardware perspective
where we need to upgrade and then making a plan. So once weíve established our current
state, then we bring those IT and clinical programs together -- the right people, right?
The people that do the work -- we bring them to the table and we say, ìBut what do you
need to get to our goal? What do you need to enter that data?î Okay, you need mobile
platforms, you need single -- what do you need to make it work for you? And then we
design and we pick -- we design the acceptance criteria. We pick a vendor and our software
and hardware platform if you donít have one. The next key is establishing timelines. Remember
the fiscal year is changing on October 1, so we have a 90 consecutive day reporting
no later than July 1 of each year and [spelled phonetically] we need to make sure that we
hit our project well above that, right, because the 90 day, we canít be implementing or fitzing
[spelled phonetically] around. Weíve got to be hitting our threshold consecutively.
The adoption must be there. So I like to get everything into place by about June of the
year that youíre going to look to attest, making sure that youíre strong for that last
month and then just pick the day that youíre going to attest. Now, in 2014, that game changes
ever so slightly and the government says you must pick a recognized quarter, right? So
you canít just pick any day of the year. You have to pick a recognized quarter and
start on the first day of that quarter. And as for [spelled phonetically] your timeline
now, we need to do hard dates, milestones, making sure that we have a schedule that weíre
marching to, everybodyís in alignment, and then we have some way of reporting or communicating
those strategies to keep people in alignment. And communication strategies are important.
Hospital people like to be told they do a good job because they do a good job, right?
Wouldnít you want to leverage the great work they do every single day? We donít want to
make them do more things; we want to demonstrate how they are doing such a good job, and you
need to have some way of doing that, whether itís in Excel, or whether you color the cells,
or we do a dashboard -- some way where we train them on what theyíre doing and the
joy that they are bringing [laughs] all of us at a hospital level by implementing the
data, by entering the data that weíre asking them to do.
The next thing that has changed over the last few years, which weíre delighted that itís
changing, is embracing evidence. Now, in many of our CAH facilities, we have a lot of people
that have been practicing there for a long time. Maybe thatís the only place theyíve
practiced. Theyíve been in practice 30 years like myself and, you know, weíve always done
it a certain way. It seems to have worked all those years. Why canít we just continue?
Well, like it or not, there is evidence to suggest that if we do things a certain way,
we have better outcomes, right? And we have research and knowledge to do that [spelled
phonetically], and you can debate it all you want, but it is out there and the federal
government has it. Not only is it out there, but the ability of this thing to be real time
[laughs], because the internet is out there. So -- and itís not just clinical data anymore.
Itís how you have to establish your HIT [spelled phonetically] platform for the clinical programs
to write on top of to be stable that has best practices. So best practices in data information,
structured data, best practices in terms of hardware, software, Citrix, infrastructure,
desktop configurations -- thereís knowledge on clinical decisions of course [spelled phonetically].
A lot of this stuff though is behind the scenes. Itís embedded in the software programs so
your clinician just has this stuff coming to them. Itís a very passive receipt of guiding
decisions for care and then documenting with it when the clinician decides not to provide
the care along the guided pathways, like care plan or care pathways, and itís just becoming
more defined and itís embedded in all the programs and it just is what it is. Now the
unique thing about CAH is that you only have certain, letís say drugs available in your
formulary [spelled phonetically] so you can tailor evidence-based to your unique program
and your unique patient population. Easy to do.
The next thing we need to look at is aligning all the partners, right? Hospitals have a
tendency to believe that everything exists within their four walls, but in fact, as our
patients leave our care, right, they engage with other care practitioners, okay, whether
itís the pharmacist, whether itís home care, whether itís their primary care or another
clinic, a pain center, long-term care, assisted living care -- everybody is providing care
to these patients, and as a community service agency, which a hospital is, we need to align
ourselves or our partners with us, at least letting them know what weíre doing so everybody
has a heads up on success as we engage in outcome data for our patients.
In addition, we have to look at how is it weíre going to educate these people. So in
our long-term care division, they are being inundated with their own regulations all the
time, and so itís a matter of aligning that depending on how close they are with your
CAH facility, whether itís part of, a wing of your CAH facility, or whether theyíre
a separate entity, itís aligning all of those regulations, training everyone to them so
we donít get confused, where we have a clear vision of where weíre going and then we can
communicate that clear vision. And as a matter of fact, not only do we have a vision, but
weíre going to measure that vision. Weíve established criteria by which weíre going
to measure and weíre going to report those measurements. Weíre going to report our successes,
not just in the quarterly QI reports that have been down [spelled phonetically] in hospitals
all the time, but in a very assertive way saying we have met the threshold for caring
for our acute heart attack patients, for our diabetic patients, that we have metrics aligned
within the hospital and with our program -- the meaningful use program -- so that we donít
come in conflict. We donít cause confusion for our providers and our clinicians of what
weíre asking them to do and then we want to report that. We want to report that theyíre
doing a great job, which is called adoption, because our program, by the way, really is
about the Medicare patient, right? But hospitals care for all patients and so
we want this great work aligning with all patient care. In our report cards, when we
get to a testing to the federal government, we will then be able to include and exclude
what the government has decided for the right patients -- you know, where our pediatric
patients lay, where our -- you know, our geriatric patients might lie in a -- at a station. Okay.
The other thing that is very fascinating to me as I pointed out at the very beginning
is the HIMSS Analytic model -- the EMRAM model has measures that say there is demonstrable
proof that if you align your adoption technology along a certain pathway, which the federal
government, by the way, to a large degree followed, you will have predictable outcomes.
You will have return on investment -- demonstrable return. And so we can align our MU strategies
-- meaningful use strategies with the HIMSS Analytic model and position your hospitals
for very high levels of integrated technologies and adoption and utilization of the data in
an electronic format. In terms of implementation, we have to look
at what -- how do we implement these things in our hospital? How do we make it work, right,
and how -- where are we going to implement along the strategic plan -- along the strategic
timeline? And with implementations along with the development of the software program and
the deliverables, you need to have dates and these dates need to include training dates,
bow-line [spelled phonetically] dates, support dates, and along this timelines for implementing,
you have to outline all these work efforts. So you have 26 projects moving forward all
at the same time for meaningful use -- again, some are easy, some are not as easy -- but
along the way you want to show how youíve embedded the implementation components -- the
implementation methodology such as training, such as readiness, such as goal life [spelled
phonetically], and nothing will provide you more success than embedding the MU program
-- the R [spelled phonetically] program into your clinical workflow. If you can get the
subject matter experts in your hospital to design the requirements in their workflow,
youíve got it hands down. It [spelled phonetically] absolutely can show that they will then follow
the pathway because we outlined it. They designed the pathway, right? So itís providers, if
they have time, itís certainly nurses, itís respiratory therapists, itís pharmacists
-- inviting the right people determines their current practice and not forgetting HIM, which
controls the legal medical record in most hospitals -- health information management.
It used be called medical records. Making sure you have milestones clearly outlined
because we have very hard dates --prescribed hard dates by the federal government and then
make sure that you have a reporting strategy up to your alliances -- your leadership alliances
so that you can have them support you or intervene should you not be able to obtain something
because of a barrier, whether itís a real barrier or perceived. The other thing Iíd
like to point out is make sure you update your policies, right? Policies need to be
updated because other agencies that come and audit us like DOH -- Department of Health
and Joint Commission -- they like to see that your policies align with your practice. And
it can be easy. You can have one line or two that says this is how we deal with all of
our policies during [spelled phonetically] electronic format. Youíre not to forget that.
Okay. Again, this is an outline of what you hospitals -- what your role will be, okay?
You need to define the technology that you want -- the certified technology and then
hereís your part: making sure you understand the data thatís required, making sure you
align it with your clinical initiative, and then stick them into the workflow, and analyze
whether your design worked in the workflow, make the tweaks your need with your core team
-- your hospital core team does this role, and then the rest of it typically is done
behind the scenes. Okay? So the integration of the data -- the alert and that the clinical
decision support programs that are embedded -- they are truly embedded. They are under
the sink [spelled phonetically], so if sepsis is important to you as a hospital, if stroke
is important to you, we can integrate technologies that provide alerts to clinicians and other
caregivers to provide the outcomes that we want to guide them on the care treatment plan
to provide the outcomes -- the output reporting that we want and need.
And then for our CAH facilities for implementation, we really need to look at how are you going
to actually implement and this has to go back to your timeline. What time do we have to
implement? If youíre looking to attest this year and you havenít implemented everything,
which means you have to start your 90 day reporting July 1, likely youíll need to go
with Big ***. You may not have a choice. And Big *** approaches in CAH facilities
are very, very successful but they can be painful -- painful because you need lots of
resources -- resources to support your clinicians 24-7. And we call those resources red shirts
and blue shirts. So some resources designated just to help doctors and some to help the
operational work efforts of all the other clinicians to make sure your hospital continues
to operate and you provide the care you want. And often in Big *** approaches we need extended
support models; so six weeks to 90 days out we have to have support. And the reason is,
okay, because when you do Big ***, itís kind of a -- itís like an overwhelming aha
[spelled phonetically] to clinicians and after a week or two they sometimes slip back into
old habits and weíve got to make sure that that doesnít happen, okay? So weíve got
to have this really aggressive change management. Like, if theyíre slipping back because we
designed it wrong despite our best efforts and we need to make a change, thatís okay.
Itís all right. We donít want to do that a lot, but we can do that. But itís more
an -- a time when these folks kind of go into workaround, we call it. And workarounds do
not generally meet the federal requirements of data entry in the coded and structured
fashion as opposed to what we call phasing go-lives or rolling go-lives -- very effective
as well at CAHs where you bring up, you know, certain programs together. Like, you bring
up -- you know, e-prescribing [spelled phonetically] and position documentation together or e-prescribing
and other types of things together. And the reason we -- this one works a little
bit -- itís a little less stressful for a hospital although it takes more time is that
the support services that you have to have available are more focused, right? They donít
have to be all over your hospital. Theyíre focused on the area of the hospital that -- and
the project youíre implementing. You still have to have their blue shirts there [spelled
phonetically], your docs [spelled phonetically] in the red shirts for all your other clinical
systems to make sure your operations are efficiently run, but it is a little bit less painful and
even though you have to have support for, letís say, six weeks, itís not as massive
and in general you do not see the people slipping back quite as -- a little jep-ner [spelled
phonetically]. But it is -- Big *** works and weíve done both -- very successfully
done both. You just have to think about how youíre going to do that.
And then we obviously want to monitor. We want to give feedback. Feedback to our clinicians
is extraordinarily important, right? They love to do a good job because they do a good
job. They love to know it. We use red, green, yellow. Green means everythingís great. And
remember in our stage one, the thresholds arenít 100 percent. Well, whatís interesting
about hospitals is they want to get 100 percent, right? Why am I not at 100 percent? Itís
all right, right? We only need greater than 30 percent [laughs]. Could we be happy with
that? But anyway, however you want to report back to your clinicians -- giving them feedback
on the great work theyíre doing and then targeting the areas that you need to focus
on, okay? And this isnít making massive changes. Thatís why you want some sort of threshold
or dashboard that looks over time because time gives you a great view of every weekend
or every other weekend when this clinician works, our numbers fall, right? And so it
gives you an opportunity to provide additional resources to that clinician to help understand
what the barriers are for them. And then process management or project management
-- this is a key item that weíve seen emerge again over the last several years and particularly
in the health care space as more and more of these projects are having to be implemented.
And project management is typically is not necessarily done well with the current people
that are hired in the hospital unless you have somebody youíve hired to project manage.
And I just say that because in most hospitals, particularly our CAHs, all of these people
have tremendous relationships, right? And so if somebody doesnít want to quite meet
their deadline or whatever, itís sometimes hard to have those dialogues when you have
all these relationships with these people. Itíd be a leverage point as well, but sometimes
problems. So project managing methodologies really are
black and white and they give us project plans; they give us timelines; they help us identify
cost centers; they help us manage cost centers or be putting the cost into the appropriate
bucket so we can report accurately on our cost accounting, our cost reporting; they
can really identify where -- like if someone has to go out because theyíre -- you know,
theyíre going to have a baby -- maternity leave for three months, that might be the
only person from that department on the core team, right? So they can begin to project
and predict those people costs of how youíre going to manage that both in a dollar sense
and in a subject matter sense if we lose that particular person.
And then again, soft costs, all the meetings, all the work efforts besides just the specific
implementation -- they can rapidly identify and predict resource requirements and resource
requirements when theyíre needed. You donít need somebody all the time, but you may need
a pharmacistís help, letís say, in the month of May, right? And they can begin to outline
that early on in the project. They help define an escalation pathway for when people want
changes, and I will tell you that people will come out and they will want changes. Itís
fantastic. We love everybodyís great ideas, but itís not likely that we can implement
all those great ideas, so we need to have some sort of way to -- that everybody understands
of how weíre going to adopt the change necessary and how weíre going to manage these great
ideas from all these creative people who have always been involved in the operational components
of our hospital. And so we use things like parking lots or letís put that on the, you
know, to-do list, or the action-item list, or phase-to [spelled phonetically] or however
you want to define it, because itís a very slippery slope when you start making lots
of changes. And again, every expert -- everybody involved in your hospital is an expert and
they have great ideas and what youíll have to determine is how youíre going to incorporate
those great ideas and how youíre going to get back to people so you donít discourage
that creativity and that innovative, you know, environment that weíre trying to create in
our hospitals and then they can track for us. They can create these dashboards and track
how weíre doing. Now that -- the last phase is in this particular
CAH is from going on -- okay, now what? So we designed our strategy, we know what weíve
got to do, weíre marching towards it. Now what? So a couple of things in the now what
area is to start your audit books. Okay? Starting your audit books, preparing your programs
for audit do a couple of things. One, they protect you, right, when the audits. We talked
about the audits. Theyíre coming. ONC -- the Office of National Coordination [spelled phonetically]
and the Center [spelled phonetically] is very interested in ensuring that hospitals that
attest have in fact met meaningful use. Thatís fair, okay? But the audit books do more for
you. They begin to define for you a gap analysis preparing you for stage two which you will
know in your audit book how you met every core menu objective or which ones you chose
to defer. They will outline you to a large degree the work effort required for stage
two. Itís fantastic. So you can take your stage one work effort, you can put together
your audit preparation with books, and from that you can glean your current state as it
relates to the next journey which is stage two or whatever your next journey is.
Organizing that data -- right? This is where your project manager can again be very, very
helpful. And then maintaining that data -- remember, you have to maintain the details for six or
seven years, right? You have to maintain and store how you met meaningful use stage one.
We do not recommend storing PHI in the audit books. PHI, right -- Protected Health Information.
This is your patient health information, right? That needs to be stored somewhere else but
store it is [spelled phonetically] because thatís the data where you got the numerator
denominator value to attest for meaningful use. So very powerful -- your audit books.
And hereís some audit links that the federal government recently released in February about
how to prepare for audits. Now this preparation is more aligned with the CMS audit agency
that is coming around and sort of saying how did you prove -- prove to me that you met
meaningful use for the full 90 days consecutively. Now I did not particularly find these helpful,
but itís a start and the government lease is giving us something because when we were
audited they gave us a big fat nothing. But thatís all right. Theyíre getting better.
And then the next thing -- so weíre going to attest. Now weíre auditing, weíve got
our audit books, weíre ready to attest, right? So weíre in our 90 day monitoring and weíre
working with our finance division, make sure all the registrationís ready for attesting,
weíve got our reports in sync, weíve validated the reports, are bringing the right people.
Weíre not implementing. Weíre not changing in the 90 days, right? Weíre showing how
weíve met our established metrics -- these are metrics established by the federal government,
not us. Not us. And weíre saying, ìAll right. Weíre ready.î So during these 90 days, right,
because weíre in 2013, you can begin to analyze -- assess the current state for stage two
because you have your audit books. You have your attestation books. Do -- you will know
whether you included your ER and whether or not youíre going to want to leverage that
strategy for stage two. Right? Youíll know how you implemented CPOE, and this is a gap
area. Some people play the game that they just did a couple of things in CPOE, which
is physician [spelled phonetically] order entry, right? Computer position order entry
is what CPOE stands for. Some people just did like one or two med orders to meet the
game, right -- to play the game. Well, thatís probably going to get you in stage two.
So that will be a large work effort that you could start planning now once youíre in your
90 day reporting, right? Once youíve got your audit books ready. And then really looking
at how are you going to engage your patients? What is your community tolerance level? What
are your unique features of your community? And then as you know, the electronic medical
-- or medicine administration record, the eMAR -- and donít be fooled. Stage two you
must use barcode medication verification. So if you have not used that, youíll need
to use that in the future. Youíll need to implement that. So in your 90 day reporting
period not only can you prepare for stage two, you can make sure youíre ready for your,
you know, 90 day -- your stage one year two which is a full 12 months, unless youíre
reporting this year in which then your stage one year two is a 90 days on the calendar
-- on the recognized quarters right? So all the rules again -- remember the rules. But
again, itís a great time to prepare for stage two planning.
And along that planning journey is a great time to sit back and say, okay, what have
we learned? What have we learned about preparing and planning and the barriers [spelled phonetically]?
What have we learned about understanding the language, understanding the rules, understanding
the timelines, right? Did we play the game well? What could we do better? What could
we do different? What did we -- did we do well with our leadership team? Did they need
anything else? Do they want something different in our next year? How did we do on strategic
planning? Did we align well or did we have a hiccup because we forgot to stick in that
weíre moving to a new building right in the middle of our attestation period? That would
be a problem, right? How did we align our partners in care, our doctors, our long-term
care, our home care, our assisted living, our community pharmacies? How did we align
them in this journey and did that go well and get feedback from them, what we at the
hospital could have better or different. Metrics -- did we meet our metrics? Theyíre going
to go up. With the metrics we set, we [spelled phonetically] went up for us. Did they position
us strong enough for stage two and stage three by the way? And then look at our implementation
workforce. How did our strategy impact them? Did we burn them out? Are they playing the
game with us? Are they interested in continuing? Do we need to give them some fun things like
mobile technology, tablets, or other things to make sure that they continue to work with
us? And how did our project management or our process management work? And all of that
together really becomes an impact statement of how meaningful use stage one worked in
your particular program today, yeah. And you can then leverage that impact statement
for going after -- if youíre a gap in dollars, you can go after grants. If youíre a -- you
have a gap in workforce, identify that you thought you could meet in stage one but now
youíre questioning whether you can do that as strong in stage two. You could really begin
to look at your lessons learned and take those strategies, taking the good, leaving the bad,
reengineering the bad to something different, and trying it again. And Iím going to tell
you that every time you do this, you get better. So even though weíve done, I donít know,
20 plus meaningful use programs with 20 plus different, unique CAHs, we still learn because
each agency has their own unique talents, their own unique gifts, and their own unique
expertise that they share and then we have the pleasure of sharing with the next hospital.
So hopefully this talk has given you confidence in engaging today in your hospitalís involvement
in the meaningful use platform as outline by the federal government but not just for
that reason, not just for the aura incentive dollars, but more for your community, positioning
your organization in your community of patients very strongly in the next two to five years
of healthcare as the government continues to push for -- towards transformation and
it will position you very, very strongly as you engage with other facilities in your region
whether you choose to participate in an ACO, whether you chose to participate in the statewide
HIE. But it gives you leverage, gives you options that you may not have if you choose
not to play in this fantastic journey. So hopefully this has been helpful, and I appreciate
your time, and thank you very much.
[end of transcript]
HHS: 091010 More Magazine Interview 2 5/24/13
Rural Hospitals Achieving Success An Amazing Journey 28 5/24/13
Prepared by National Capitol Captioning 200 N. Glebe Rd. #1016
(703) 243-9696 Arlington, VA 22203
Prepared by National Capitol Contracting 200 N. Glebe Rd. #1016
(703) 243-9696 Arlington, VA 22203