Margret Amatayakul

The American Recovery and Reinvestment Act (ARRA) provides $17.2 billion to reward Medicare and Medicaid providers that use certified healthcare IT  in a meaningful way, starting Oct. 1, 2011 (with an "adjustment" for those not using such systems in 2015). That's only about two and a half short years to prepare for the incentive or six short years to avoid the sanction.

For many hospitals, taking full advantage of the ARRA incentives will not be easy. There are only about two dozen vendors offering products that have the potential for inpatient electronic health record (EHR) certification, and of those, only about half are certified by the Certification Commission for Health Information Technology. But even if a hospital uses one of these vendors, it may not either have the certified version or be using the components that constitute a "qualified EHR" under ARRA.

This qualification includes the "capacity to capture patient demographic and clinical health information, such as medical history and problem lists, provide clinical decision support, support provider order entry, capture and query information relevant to healthcare quality, and exchange electronic health information with and integrate such information from other sources." Although subsequent regulations are needed for further clarification, to demonstrate "meaningful" use, a hospital will be required to report clinical quality measures from its EHR system.

Moreover, results of recent research disclose that fewer than 2 percent of nonfederal U.S. acute care hospitals are using a fully functioning EHR in all departments, and 12 percent are using minimum basic functions of EHR in at least one department.a The Healthcare Information Management and Systems Society estimates that only about 4 percent of hospitals have computerized provider order entry, closed loop medication management (barcode medication administration record systems), and clinical decision support.b

Yet another challenge for hospitals is generating data for clinical quality measure reporting. Many hospitals today require a large staff to abstract data for core measures-even from their electronic systems. Hospitals require such data abstraction because information is often recorded in paper documents, which must be scanned, making the data difficult to capture in discrete form.

Help Is Available-to a Degree

What, then, will it take to adopt the necessary systems? Initially, the concern was that capital markets are so tight today that hospitals would be hard pressed to acquire new systems or even add-on components. However, the stimulus legislation does provide some potential help in this area from an array of spending provisions, such as temporary federal medical assistance percentage (FMAP) funding, a temporary increase in disproportionate share hospital payments, continuation of COBRA coverage, grants and loan opportunities, moratoriums on some Medicaid and Medicare regulations that would have cut certain payments, and incentives for banks to purchase hospital tax-exempt bonds.

But even with this help, many are concerned that vendors will be challenged to support the number of implementations required to get all hospitals up to speed, and many organizations may not be capable of adapting to the changes brought about by the new systems in time. Many hospitals will probably be hampered more by these two factors than by lack of up-front funding, as these hospitals may already have acquired but not fully deployed the modules needed.

The stimulus package also includes funding for training healthcare providers in health IT. But obviously, education takes time, as well.

Further, there is a provision to create a health IT research center and regional extension centers to provide assistance. Again, however, time and great care are also required for much of the "people" elements of implementing systems.

Some Recommendations

So short of deciding to take the hit in 2015, how does a hospital gain the time and human touch to prepare? The following are some suggestions.

Look internally for staff who can help.
Hospitals almost always have a number of professional staff members who have skills in project management and workflow redesign and may not be formal project managers or management engineers-but who could easily take on these roles with a small amount of additional training.

Look for help from other industries that are laying people off in your community.
Hospitals have traditionally paid less for IT staff than other industries, but in hard economic times, some money is better than none. These individuals may also provide a new perspective on how to introduce change.

Don't delay your adoption. Conduct an assessment now of what has been implemented effectively, what has been implemented but is not being used to its fullest extent, what you have "on the shelf" ready to be implemented, and what you need to acquire. Prioritize your migration path to reflect what is needed to take advantage of the incentives. Many hospitals already have in place the foundation systems necessary to move forward from a technical standpoint.

Evaluate your corporate culture.
If mandates for physicians to adopt CPOE have not been your style, it may be necessary to rethink this position. Some "tough love" may be needed-and may actually help your physicians overcome many of these same issues in their own practices.

Engage all stakeholders, and promote entrepreneurship and innovation.
Despite the potential need for a mandate from you, your health IT initiative will not be successful unless everyone gets involved. It may be necessary to find creative ways to get someone to the table or to take some risks with new approaches to processes and workflows. For instance, you may ask physicians involved in medical staff activities other than the EHR to develop use case scenarios to help in system design, testing, and training and urge them to utilize their peers to support this activity as well.c

Open your "doors." Much of the health IT component within the stimulus package is about health information exchange. The new privacy provisions include a focus on personal health records (PHR) and access to information. Healthcare organizations have been slow to adopt patient portals, kiosks, and other means to engage patients in the process of supporting information. Yet there is good reason for you to move quickly in this area. Your patients or their family members can ease the data entry burden for clinicians and ensure more complete information through use of PHRs and participation in health information exchange.

Margret Amatayakul, RHIA, FHIMSS, is president, Margret\A Consulting, LLC, Schaumburg, Ill. (


a. Jha, A.K., DesRoches, C.M., et al., "Use of Electronic Health Records in U.S. Hospitals," The New England Journal of Medicine, March 25, 2009; 360:1-11.

b. EMR Adoption Model,SM HIMSS Analytics, 2009 ( 

c. Amatayakul, M., "To Achieve Clinical Quality Improvement Through IT, Engage Physicians," hfm, May 2007.

Publication Date: Friday, May 01, 2009

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