$20B Shot in the Arm

  February 17, 2009, the world changed for every healthcare provider in the country when President Barack Obama signed into law the American Recovery and Reinvestment Act. Among the many provisions included in the “stimulus bill” was a piece of legislation known as HITECH, or the Health Information Technology for Economic and Clinical Health Act. In what must have seemed like a novel idea [sic] to some legislators, HITECH is actually a funded mandate, to the tune of $20+ billion spread around at least 11 different federal agencies. Originally part of President Obama’s Healthcare Reform Act planned for later in the Obama administration, HITECH, like many other provisions in ARRA such as the selection of ‘bourbon’ as the National Spirit, suddenly became stimulative. This change happened after the President declared our country’s economy in a state of emergency allowing the Congress to suspend their ‘pay-as-you-go’ rules, which require new legislation to define from where the money will come to pay for the program.

Leadership

  Perhaps the most important piece of this legislation is the formalization of the Office of the National Coordinator for Health IT (ONC). Established by Executive Order by President Bush, the ONC has now been codified and made permanent. More than permanency, the ONC now has real responsibilities and a ‘real’ budget of $2B to carry them out, which represents a 3,333% increase over its previous $60M budget. To supplement the National Coordinator’s leadership is the formation of two committees, the HIT Policy Committee and the HIT Standards Committee. Like their names imply, the Policy and Standards committees were established to make policy and standards recommendations respectively to the ONC.

  The ONC now has an extremely important date engraved on its calendar. The formation of these committees, the selection of a set of recognized standards, and the selection of a certification path for going forward are due by December 31st of this year. Considering the time that it takes to create these bodies, standards, and certification specifications, the ONC is under significant pressure to get this all done by the deadline. This suggests that the ONC will likely make these selections from organizations that already exist leading the author to believe that the role of HIT Policy Committee will be filled by the National eHealth Collaborative (NeHC) and the Health Information Technology Standards Panel (HITSP) will be cast to play the part of the HIT Standards Committee. The last bit of this forecast is that the Standards Committee will recommend the Certification Commission for Health Information Technology (CCHIT) to the ONC to provide the certification criteria for the nation’s electronic health records.

Funding and Incentives

  To carry out the plans set forth by the ONC and these committees, the Secretary of Health and Human Services (HHS), acting through the National Coordinator, will be fueling the creation of a national health information network and the adoption of electronic health records by providers through two primary funding programs. The first program is a series of grants, matching-grants, loans, and matching-loans made through various grant and loan programs established by the States in cooperation with the Secretary. These funds will be used by providers to carry out such activities as facilitating the purchase or enhancing the utilization of certified EHR technology, training personnel in the use of the technology, and improving the secure electronic exchange of information.

Physician Incentives

  The second program will come through the Centers for Medicare and Medicaid Services (CMS) and at $17.2B represents the largest portion of the funds allocated by HITECH. The flagship CMS program will be the establishment of incentive payments through Medicare for the “meaningful use of certified EHR technology by eligible professionals and hospitals.”

  There are at least three 800-lb gorillas in that sentence, and it is all about interpretation. The irony of such semantics in a discussion about semantic interoperability is actually quite comical! The first is the definition of meaningful use, which is a broad, vague term to describe a physician who 1) uses a certified EMR, which includes ePrescribing, 2) their EMR is connected to a health exchange network, and 3) submits information on clinical quality measures to CMS. The next is the definition of a certified EMR. As we discussed above, while we have insights into what a certified EMR will probably look like, vendors are being forced to develop new features without any clear roadmap until the end of this year. Finally, the term ‘eligible’ is going to exclude hospital based physicians such as pathologists, EM doctors, and anesthesiologists. At this time, it is unknown if physicians who practice solely at a hospital outpatient department (HOPD) will be included in the exclusion group, cross your fingers!

  In exchange for meeting all of the requirements mentioned above, an eligible physician will receive incentive payments for the first five years (FY 2011 – FY 2015) of the program. In the first payment year the physician will receive $15,000. In subsequent years the payment changes to $12,000 (FY 2012), $8,000 (FY 2013), $4,000 (FY 2014), and $2,000 (FY 2015). However, this is not just something that physicians can just sit idly by and note that they are missing out on a bonus. If an eligible physician has not become a meaningful EHR user by 2014, they will not receive full Medicare payments beginning in 2015. Their fee schedule will be reduced by 1% each year until 2017 where they will continue to receive only 97% of their reimbursement until they meet the definition of a meaningful user.

Hospital Incentives

  Hospitals are also going to receive incentive payments through the legislation, for the first five years of the CMS program. The hospital has to meet the same definitions of meaningful use, but the payment formula is entirely different. Hospitals who meet the meaningful use definition will receive an incentive payment between $2M and $6.4M depending on the number of inpatient discharges. That figure is further reduced by multiplying it by your Medicare case-mix and the program year which will be reducing payments per year. Finally, with a bigger carrot comes a bigger stick. Hospitals who fail to demonstrate meaningful use by 2015 will see their Market Basket Adjustment percentage increase reduced substantially, dropping by thirds over three years until it is non-existent by 2017.

  In summary, to get these incentive payments, an eligible physician or hospital must use a certified EMR, the definition of which has not been established, connect it to a regional or national health exchange network, which does not yet exist in 85% of the country, and must participate in one of CMS’ Pay For Performance (P4P) programs such as PQRI which at this time doesn’t collect any quality measures that wound care physicians would meaningfully benefit from collecting, and if you don’t have these items in place in the next 5 to 7 years, not only will you miss out on substantial bonus payments, you will start to have your practice financially penalized!

Nationwide Exchange of Healthcare Information?

  Anyone who has been unable to get patient records from a hospital across the street will understand the conceptual appeal of “nationwide exchange of healthcare information.” Let’s assume for a moment that the enormous obstacle of the HIPAA privacy issue could be managed and consider the obstacles to information exchange. Let’s even assume that the obstacles to electronic compatibility were easily overcome. The real challenge is one without an obvious “fix” on the horizon. When I was in college there were 6 other students with the relatively common name of “David Walker,” at my institution of 30,000. Fortunately, we could be distinguished by date of birth or social security number, but even this did not prevent us from occasionally receiving each other’s grades, and invoices. By what mechanism will we agree to identify each person in the USA to determine that the records belonging to each one represent only that person? We cannot use Social Security numbers since non-citizens do not have those. A universal “key” to do this has not yet been created or agreed upon, and yet there is a deadline for performing this task, after which physicians might be financially penalized.

The Impossible Marathon?

  Now, let’s put some of these new rules, regulations, and funding into perspective. In 2008, the entire healthcare IT industry had an estimated budget of $26 billion. Thus, these acceleration funds will nearly match the entire budget of the current industry. Healthcare IT professionals we will be given the biggest challenge of their careers to implement changes that are by no means easy. It will be ‘a continuous IT marathon.’ It is not clear if the right tools currently exist, or that there are enough people with the skills to make this happen at the pace Congress requests it. HITECH does include an education and outreach program to provide matching funds to institutions of higher education, which establish or expand their medical health informatics programs, but frankly in this author’s opinion it is too little too late. The current IT landscape is littered with computer science graduates trained at schools that have abandoned the hallmarks of computer science training in favor of teaching Java to produce more students for the ‘dot com’ era. The end result, like nursing, quality healthcare IT personnel is in dire shortage. The end result is that our existing IT staff will have to do this job alone. Individuals, whom make a living programming EMRs, have been preparing for these changes, but the task ahead of us is indeed daunting. If you use an EMR in your practice, now is the time to ask your provider how they plan to handle the new requirements from the HITECH bill, and if you are shopping for an EMR, you do not want to commit to one that does not provide reporting for PQRI (Physicians Quality Reporting Initiative) or one that will not commit to you that they will have a certified EHR product by January 1, 2011. A generation that included many of our grandparents was known as the ‘Greatest Generation.’ Will we be the ‘Greatest Healthcare IT Generation?’ Or will we be seen as the generation who swallowed the poisonous pill?

  David Walker is President and CEO of Intellicure, Inc., a specialized electronic medical records company focused on wound care in The Woodlands, Tex. For more information visit www.DavidOnWoundCare.com.