Here’s some scary news. A new report from the Government Accountability Office (GAO), the federal government’s watchdog agency, has recommended that the MU program do more to verify that providers actually qualify for incentive payments.  Given that CMS already plans to begin auditing already-certified providers after they get their incentives, we could be looking at some disasters in the making.

The GAO, which conducted a review of the first year of Meaningful Use, looked at both the Medicare and Medicaid EMR incentive programs. It analyzed Medicare MU attestation data from last year, as well as looking at the verification processes used by Medicaid programs in four states and interviewing subject matter experts.

Along the way, the study picked up some interesting data points. For example, the agency found that 80 percent of hospitals and 72 percent of eligible professionals decided not to report on at least one mandatory MU measure, a loophole allowed by the program. (Hospitals can dodge up to three measures, and professionals six, if the measures aren’t relevant to their clinical practice or patient population.)

The bottom line is that the GAO recommends that CMS increase the number of prepayment verifications it does; set up timelines which will speed the process of evaluating audit effectiveness; offer states the option of having CMS collect MU data for both Medicare and Medicaid; and (the big one) collect additional MU verification information from providers from Medicare providers seeking the MU bucks.

As it is, CMS plans to start a “post payment audit” program this year which sounds as if it could involve clawbacks of already approved moneys.  It’s hardly a new trick for CMS, which already does this already happens when our friends the Recovery Audit Contractors think you’ve made Medicare claims mistakes.

Meaningful Use incentives may have boosted EMR adoption dramatically, but the incentive program has had an uneven effect on the industry, new research suggests.

According to a new study published  in the journal Health Affairs, the EMR adoption gap between small- and large-hospitals is substantial and growing.  The study drew on responses by executives from 2,646 hospitals, or about 58 percent of all acute care hospitals in the country.

First, the good news. Researchers found that hospitals with EMRs grew from 15 percent in 2010 and 26.6 percent in 2011. They also found that the number of hospitals with a “comprehensive system”  rose from 3.6 percent to 8.7 percent, according to a piece in Information Week.

The not-so-good news, however, is that not all hospitals are joining the party at the same rate.  The study reported that 15 percent EMR adoption gap seen in 2010 has grown to almost 22 percent last year.

And the problem doesn’t end there. As Chantal Worzala, director of policy at the American Hospital Association and co-author, told the magazine, it’s clear that smaller hospitals’ problems may get worse over time.

As hospitals struggle to move through MU stage one and move into Stage 2 compliance, smaller hospitals are likely to get further and further behind, as they don’t have the infrastructure or staff to allow for high-volume exchange of clinical data.

So, what should happen next?  Researchers had a couple of suggestions for policy-makers:

* Consider lowering the MU Stage 2 bar for smaller, rural and nonteaching hospitals
* Create a special program designed to bring hospitals with little health IT in place on board with an EMR

Short of buying systems for half the country’s hospitals, though, I don’t think the government can do much to  eliminate this adoption gap. With hospitals short of IT staff, facing a tight budget and running on a narrow or non-existent margin, moderate incentives and pressure alone won’t do the trick.  Readers, what solutions would you suggest?

Computerized Physician Order Entry (CPOE) adoption rates have been very slow over the last few years, but now, driven by Meaningful Use pressure, more providers are adopting such technology.  That being said, a goodly number of providers still haven’t managed to speed adoption, largely due to doctors’ resistance to changes in workflow, according to a new survey.

The survey, in which vendor Imprivata looked at HIT trends, found that 45 percent of respondents were seeing success with CPOE adoption, with more than half their doctors placing orders using CPOE. This represents substantial progress from a few years ago, when I was seeing studies citing total adoption rates below 10 percent.

That being said, 38 percent of respondents said that less than 25 percent of doctors were using CPOE. What’s slowing things down? Sixty-three percent of respondents said that physician resistance to workflow changes was the hangup.

When asked what technologies could speed adoption of CPOE, respondents said single sign-on (74 percent), virtualized desktops (48 percent) and remote/mobile access (46 percent) were all effective ways to engage physicians in CPOE use. I’m not surprised to hear that single sign-on leads the pack; anything that reduces the hassle factor for users has got to be a winner.

By the way, these trends are fairly consistent previous year’s research, in which the vendor found that 82 percent of respondents considered single sign-on a key factor in CPOE adoption as well as meeting Meaningful Use goals.  It’s worth remembering, when talking about SSO, that Imprivata is a security vendor, so take the prominence of that stat with a grain of salt. Still, I thought it was interesting and probably a valid observation.

By the way, Meditech’s solution ranked well at the top for preferred CPOE systems, with 24 percent using it in their facilities. Cerner and McKesson each had 14 percent of responding firm’s business, Siemens 10 percent and Epic 9 percent.

Offering subsidized EMRs to doctors may be a good idea, but if they’re smart, the doctors will be very picky about the terms you offer. (After all, if they use your EMR, you’re in effect controlling part of their business!)

So I was interested to stumble over a nice list of questions to  ask hospitals before accepting an EMR deal.  Here’s the list, drawn from the excellent EHR & EMR Insights blog by EMR vendor SRSsoft:

• Does the hospital EHR have a proven track record in your specialty?
• Will the hospital EHR workflow be compatible with your practice specialty?
• Will your physicians be required to exchange data with the sponsoring hospital?
• Is the system interoperable with other, neighboring hospital systems?
• Will learning, training, and use of the hospital system interfere with your practice’s productivity?
• How will support be handled after initial implementation, and who pays for it?
• Will the hospital’s EHR vendor assist you and your physicians with creating customizable templates?
• Will the system aid—or obstruct—your ability to qualify for government incentives?
• If there are problems, will the hospital’s EHR vendor ensure that the system is compatible with pursuing meaningful use?
• Who will own your data?

I particularly like the questions regarding 1) the EMR’s track record, 2) the impact of EMR training on medical practice’s day-to-day productivity, 3) Whether the vendor would help with creating customizable templates and 4) who would own the data.

It seems to me that too often, partnerships like these are done on the basis of trust between  organizations rather than a detailed assessment of factors like these. Now, don’t get me wrong, trust is a good basis for starting talks on EMR sharing, but hospital and medical practices alike can get very badly burned by a deal like this if it doesn’t work. Let’s hear it for extra skepticism.

As they settle into their implementation, hospitals are hoping to connect key medical devices to their EMRs. But vanishingly few have pulled off connecting one important device, the smart infusion pump, according to recent research by KLAS.

KLAS’s new study surveyed 251 providers from 218 organizations.  Researchers concluded that less than 10 providers in the country are tying smart pumps to their EMRs, despite the fact that most providers see such connections as an important safety measure.  The smart pumps let clinicians know if the pumps aren’t set to match a facility’s guidelines, while standard pumps are programmed by hand.

More than half of providers told KLAS that EMR integration is a key factor in selecting future pumps, the firm says.  And they handed out higher satisfaction ratings to vendors whose technology development is moving along. Smart pump vendors Baxter, Carefusion and Hospira, for example, led in wireless technology.

That hospitals are demanding wireless pumps that connect with EMRs is no big surprise. Far too many — 23 percent — of surveyed provider organizations reported serious medication incidents within the previous 24 months.  Sixty percent of the serious errors were made while using drug libraries.  Clearly, using the libraries is good, but connecting to an EMR with auto-programming could  make a difference.

Given the difference EMR-connected pumps could make, why are so few providers already connected?  Well, one obvious issue is that only 60 percent of providers are live on wireless pump technology, which is necessary to get the integration done.

It’s not just the pump that’s an issue, however. When hospitals roll out this approach, it requires a great deal of coordination between IT, EMR users, clinical analysts and more, notes Kristen O’Shea, clinical transformation officer for WellSpan Health, who spoke with InformationWeek magazine about her organization’s smart-pump rollout.

To make sure the team worked together smoothly with the new device connections, WellSpan created a new hybrid biomedical/IT position to manage medical device connectivity. (Smart move — maybe more would be getting done in the EMR/device connection realm if they did more hiring of this kind?)

Folks, anyone who reads these pages regularly will note that I’m not a huge Meaningful Use fan, in part because the payback just doesn’t seem adequate.  After all, getting $11-odd million in incentive bucks may be great, but not so much if you’re laying out $30 million to $50 million for a system like Epic.

Well, it’s nice to be reminded that those incentives do serve some purpose. MU incentive payments apparently did some nice things for the financial health of for-profit hospitals last year, according to financial analyst firm Fitch Ratings. Fitch calculates that MU payments boost for-profit hospitals earnings by about $400 million last year.

Fitch concluded that incentives gave the hospitals a collective $396 million boost in earnings before interest, taxes, depreciation and amortization (the much-beloved EBITDA), along with a total boost in cash from operations of about $440 million.

While this is nice, it’s not exactly a flaming news story, given that a single large hospital might see revenues in the billions for a single year, so while nobody hates a $400 million boost, it’s not a huge windfall for the 1,000-odd for-profit hospitals in the U.S. And we’re talking  largely about gains to very large investor-owned chains like HCA and Community Health Systems.

What’s even nicer is that this year and next year, hospitals are likely to see larger Meaningful Use incentive payments, according to Fitch.  My bet is that hospitals still won’t come close to breaking even, but MU momentum does seem to be turning in the for-profits’ favor.

As readers know, CMS is now reviewing comments on the proposed rules for Stage 2 Meaningful Use.  Not surprisingly, one of the reviewers who’s sent in a critique is the American Hospital Association (AHA), which a few days ago sent a 68-page barrage complaining about the burden imposed on hospitals by on Stage 1 MU requirements.

Yesterday, the AHA made another MU move, this time slamming CMS’s Stage 2 proposal that hospitals be required to offer patients access their protected health information via a portal.  As I noted in the previous post on AHA, I’m surprised at how late to the game AHA is — trade groups like these aren’t known for their delicacy — and this notion has been in the air since well before CMS made it an official proposal.

Anyway, in its current letter to CMS on portals, the AHA has given them a big thumbs-down. “CMS’s plan is not supported by current technology, raises significant security issues, and goes beyond current technical capacity,” the group argues in its issue brief.

The AHA argues that with systems integration levels still dicey, hospitals are being asked to offer data in a way that may end up violating HIPAA. (Unspoken additional thought: “And then you’re going to blame us, aren’t ya, huh, you meanies!”)

Since AHA issued the statement, talking heads have popped up to bash the AHA’s position, arguing that the hospital group is dragging its feet just as the most important part of the work has begun, i.e. empowering patients to share, use and benefit from their own health information.

Well, yes and no. While I’m known for ridiculing the trade group talking heads in this business, I’d wait just a minute before we declare the AHA to be the bad guys here.

On the one hand, I can see where people are frustrated with hospitals picking this moment to complain about the task at hand. It’s not as though they’re hearing about it for the first time.

On the other hand, creating a really bulletproof portal is no joke, either, and there’s definitely some truth in the notion that making it everything it should be is very tough.  Hey, there’s no point in denying it; creating a patient portal may remain a part of MU Stage 2 requirements, but it’s not going to be a walk in the garden for hospitals.  Let’s not come down on them too hard if they flinch.

Wow. The American Hospital Association is stepping into the picture this late in the game to complain that Meaningful Use rules are imposing massive pressure on its members?  The AHA isn’t known for its reticence, after all. But anyway, it appears that this week the trade group has jumped in and started swinging.

AHA’s executive vice president and complainer-in-chief Rick Pollack sent a 68-page letter to the Obama administration this week complaining about the burden of the Meaningful Use program.

Why can’t hospitals force their way through the process to get their bucks (which, after all, can be as much as $11.5m)? Pollack apparently cited  “the high bar set and market factors, such as accelerating costs and limited vendor capacity” in his list of concerns.

He could just have easily cited a bunch of other obstacles we’ve covered here, including a lack of staff available to implement EMR projects, demands placed by the ICD-9 to ICD-10 or maybe even the fact that $11.5 million doesn’t do nearly enough to defray the sticker price on, say, an Epic installation for a mid-sized hospital (Assuming the mid-sized hospital can convince Epic to let them use their EHR software).

Given these factors, I have to agree with the AHA: it doesn’t make a lot of sense to start penalizing hospitals with non-qualifying EMRs by 2015, an eye-blink in time when it comes to planning enterprise software installations and upgrades.

So, what should the administration do?  Certainly, moving deadlines up further would be a sweet gesture, but unless hospitals had five to seven years to carry this thing through, it will still feel like eating glass for many hospitals. And of course, if the Obama administration were to do such a thing, should it offer extra bonuses to the 20 percent of hospitals which have somehow managed to meet MU criteria?  There’s far, far more questions than answers to consider here.

Honestly, I would have expected to hear this schpiel, which I sympathize with greatly, a long time ago.  Maybe it just took this long for a major news organ like Bloomberg Businessweek to understand the issues and pipe up.

Ladies and gentlemen, I’ve been following the progress of HIEs since the mid-2000s, and the story has always seemed to be the same.  HIE gets sparked by a grant or some entrepreneurial thinking, gets to rolling, looks promising, then dies because there’s not enough cash to keep things working.

Seven or eight years later, I’d love to be telling y’all that the HIE has magically matured, and that regional HIEs are taking off rapidly now that it’s clear everyone will need to be part of one at some point.  Well, I’m afraid that even that modest hope — let’s forget the National Health Information Network — doesn’t look like it’ll be fulfilled soon.

The latest downer came from the National eHealth Collaborative (NeHC), a public-private partnership funded by ONCHIT.   While the report was apparently intended to help HIEs grow, it also did much to remind us of the obstacles facing most public HIEs.

As Chris Muir, state HIE project manager for ONC recently told a press conference, the $564 million in federal funds that have been laid out to date to jumpstart HIEs haven’t gotten the job done.  He noted that in many regions, infrastructure doesn’t exist to support HIEs, but even if it does, few providers sign up. Then, even if they sign up, most participants don’t take full advantage of the network.

And wouldn’t you know it, the growth of ACOs has ended up spiking some HIE projects. For example, a successful HIE noted in the NeHC report told the conference that ACO growth is hampering his organizations operations. Some ACO providers are now blocking access to their data so competitors can’t get to it, said CEO Tom Fritz.

There’s also some technical obstacles faced by the HIEs, but those, I must say, seem solvable in an era when people are already making determined strides to allow interoperability between HIEs and outpatient EMRs. One group of federally funded HIEs, the Beacon Communities, is developing a continuity of care document that can be automatically exported to an exchange via a pre-arranged trigger, said Jason Kunzman, Beacon Community senior project manager for ONC.

Well, this is all well and good. But I still think I’ll be keeping my basic medical info on a thumb drive for now.

In response to my post on EMR and HIPAA called “Interoperability versus Usability in Best of Breed or All-in-One HIS Systems” I got the following message:

It’s unfortunate in today’s environment that we still have a “versus” in the equation. There are some systems that fall under “best of breed” and/or “integrated” and do a pretty good job at supporting interoperability. But, there remains some that rely on proprietary data models and archaic interfaces as part of their revenue stream. Hopefully as more and more emphasis is associated with clinic value derived from data exchange/sharing the “dinosaurs” will be eventually phased out

This comment prompted me to ask the question: Should we get past closed gardens and just start sharing all our data?

The simple answer that I think we all know is the right answer is: Yes, we should get past the closed gardens and start sharing our data.

All of us in our heart of hearts know this is the right thing to do. Sure, we all also know that we need to put in proper controls so that we’re sharing it appropriately, but that can be done. Why then aren’t we doing this if we all know it’s the best thing we can do for healthcare?

My simple response is that there are still financial benefits not to do it. We need someone to lead us to a point where the financial benefits of not exchanging data are so valuable that those who want closed gardens start to suffer.

This will happen. It may take some time, but the clinical value derived from data exchange/sharing will make it so the “dinosaurs” have to hop on board or become extinct.