Not a front row seat, but I had the good fortune to be in the Visitor’s Gallery for President Obama’s first State of the Union address. Regardless of one’s politics, it is a rush to be in the House Chamber to be a part of history and political pageantry.

The President spoke to the country in the shadow of the irony of the Massachusetts election. The irony isn’t what happened to the seat long held by Ted Kennedy but that the one state that has, and to all accounts appreciates, universal health care might block the rest of the country from gaining something similar.

The President took a share of the responsibility for a process that has been too partisan and pork laden for most of us. He challenged both Democrats and Republicans to stop making every day and every issue about the next election. For my part, it is clear that America does not like watching sausage being made. This doesn’t make us all vegetarians but he spoke for most of us when he said the people want fewer sound bites and more of the job getting done.

The President strongly believes in the ethical imperative of reform as well as believing it is a fundamental building block of having a strong economy and sustained job creation. Contrary to the pundits, it didn’t sound to me like he was backing away from health reform. He is not quitting.

The bill needs to be seen as only a really important first step on long over due changes for our country. This is not a criticism of Congress but a statement of reality when a country goes about trying to fundamentally improve a huge part of itself, like its healthcare system.

It will take years for healthcare providers, insurers and local communities to adapt to a complex array of new expectations, incentives and resources. In particular, those of us who care about rural health need to be nimble to address the risk of ideas developed in urban communities and frequently not tested in rural ones.

The health reform bill leaves significant challenges for future legislation and regulation and all of us to do outside of government.

No amount of “healthcare reform” can fix our own behaviors. We must work to reduce the amount of care our system needs to deliver. We must get serious about doing what we can to get and stay healthy. We need to do this as individuals, workplaces and communities.

The current system penalizes Wisconsin for the work it has already accomplished in being one of the states that stands out with high quality and relatively low costs.

Wisconsin Congressman Ron Kind was instrumental in getting into the House Bill language that requires a study about how Medicare should create incentives for value of care rather than volume of care. The study will be done by the country’s highest medical authority, the Institute of Medicine; and its recommendations will be implemented unless Congress can take action to block the changes.

Most disappointing is that Congress did not make a simple change that would have saved money and reduce headaches for rural communities. Current Medicare law limits  the number of patients the typical rural hospital can see (those paid as a “Critical Access Hospital”) to a 25 bed cap. We proposed changing that to a 20 bed average to allow for seasonal spikes in the number of patients like during a flu epidemic. Maybe this will be changed in the final Bill but currently this problem remains.

Many people have praised the new Medicare Commission as a way to modernize Medicare without “good” ideas getting bogged down in Congress. But it has key Members of Congress, in both the Senate and the House that have stood up for rural health. It is unlikely that there will be a rural perspective invited into a small Commission. The Federal law that requires proportional rural representation on the current Commission, which is only advisory, has never been implemented.

Don’t underestimate the importance of unintended consequences. It took the country the greater part of 20 years to work through problems caused but not anticipated when the way Medicare pays hospitals was fundamentally changed in 1983. It will take at least that long for all of us to digest this much change.

In 40 years working in and studying health care, I have never seen a more challenging time. I’m not suggesting that you need to hug a healthcare worker, or even your hospital administrator, yet.

On a typical day, they are working to protect their patients and community from the effect of not one storm but a plague of once in a generation storms. You see or hear about these events every day but you may not know how they pile up on your local hospital or clinic. Think of the uncertainty on the ground around federal healthcare reform, of state budget shortfalls, of physician and healthcare workforce shortages, the effects of the global recession, and of course, H1N1.  Each one of the five is a big challenge. All five at one time would cause any of us to do more than lose sleep.

Let me be clear, I am not whining on behalf of friends and colleagues who work in the front lines of health care; just the opposite– I stand in amazement at their calmness.

H1N1 brought sick patients into facilities with unvaccinated staff at a high risk of getting it and passing it on. Due to distribution problems of limited H1N1 vaccine, one nurse described the feeling like being sent into a war without weapons. Other supplies like needles and facemasks are abundant in some communities and chronically short in others. By chance, some staff got a seasonal flu shot early, while others won’t be able to get one this year.

The recession has caused the need for charity care to go through the roof. At the same time, the ability to provide charity care has fallen through the floor. Pay freezes, or even cuts, and layoffs have been necessary. The stress felt has risen.

Unemployment is at all time highs. But even in the recession, there are many shortages of health care professionals in rural communities. And hospitals and clinics are already scrambling as they work to prepare for even bigger shortages. Healthcare workers are mostly baby boomers. These healthcare workers are beginning to retire out of health care and increasingly, with age, into becoming patients themselves.

Hospitals, clinics, nursing homes and other providers are facing deep cuts in state payments that are already inadequate for Medicaid enrollees. In Wisconsin, the rightly praised growth of “BadgerCare” to expand access to insurance has brought the downside of providers being more vulnerable to further Medicaid under payment.

And then there is national health care reform. Part of me wants Congress to get it right, but another part just wants them to tell me the new rules so we can get on with it. In any event, fundamental change to a sixth of our country’s economy will require years of additional legislation and regulation. In the meantime, those of us who care about rural health need to be nimble to address the risk of ideas developed in urban communities and not tested in rural ones.

On second thought, just for prevention sake, a hug might not hurt.

The President made it clear he stands on common ground for our country by “building on what works.” A new government run plan that undermines the private sector now seems less likely. A major shift of patients into a plan paying Medicaid and Medicare type rates would harm rural patients’ access to local health care. Reform affecting rural communities must and can be built on quality outcomes and efficiency while delivering care locally. As the President concluded, I “believe we can replace acrimony with civility, and gridlock with progress.”

The shouting heads on the talk shows recently sunk to a new low in their ongoing mission to misdirect the American people. One of the national health reform bills proposed encouraging doctors to discuss end of life options with patients and families. Radicals with their own agendas twisted this into a Government plot to set up “death panels.” But it is lemonade out of lemon time. We now have the long overdue opportunity to talk about what it means to our health care when we joke “none of us gets out of here alive.”

Martians may land here tomorrow. Congress may start listening to the larger number of us who don’t shout for a living. So yes, trying to help patients and families deal with tough end of life questions can be twisted into something sinister. But when each of our time comes, most of us don’t want end of life heroics. We want to be treated with respect, to be embraced and to die free of pain.

“The practice of advance-care directives is widespread and accepted. It includes living wills with explicit instructions about what should be done for individuals in final illnesses, and what should not be done. It allows people to make ethical, legal, moral choices about treatments, prolonging life, and when additional treatment should not be pursued.” (AARP website)

“The questions are critical, even if some people find them difficult to contemplate. Should a feeding tube be installed when the patient can no longer be nourished by mouth? Should a ventilator be attached when breathing independently becomes difficult? If the patient has severe dementia, should antibiotics be used if pneumonia develops? Should cardiopulmonary resuscitation be attempted if the heart stops beating?” (The New York Times, 8/17/09)

The National Institute on Aging offers a comprehensive 68-page booklet produced under President George Bush’s Administration. End-of-Life: Helping With Comfort and Care provides “an overview of issues commonly facing people caring for someone nearing the end of life. It can help you to work with health care providers to complement their medical and care giving efforts.” Individual free copies can be obtained through the institute’s web site, www.nia.nih.gov, or by calling 800-222-2225.

While such resources are extremely helpful, I suspect most of us would also appreciate our physician or practitioner’s guidance regarding our end of life options. And in America, we tend to get what we pay for.

In the meantime, I hope the Government’s end of life booklet won’t be silenced as well. Most of us understand the wisdom in Ecclesiastes: “For everything there is a season, a time for every activity under heaven. A time to be born and a time to die. A time to plant and a time to harvest.…”

I. Three Rural Health Priorities

Assure Local Access to Quality and Cost Effective Care

·      Protecting access to local care must be a high priority. Rural health’s many successes in Wisconsin are a testament to the endurance and creativity of rural communities. State and federal laws have long required health insurers to respect the right of people to receive health care locally.

·      We believe that if a Wisconsin community has available local providers, health plan enrollees should not be forced to travel beyond that community because the health plan refuses to contract with local providers, when those providers would accept a contract with financial and quality terms comparable to other providers with whom the health plan contracts.

Address Forecasted Health Workforce Crisis in Both Rural and Urban Communities

·      The soon to explode retirement of baby boomers will lead to a critical shortage of workers, particularly in rural America for which we are ill prepared. Many rural communities already face staff shortages.

·      Make sure promoting diversity in the health workforce addresses the unique recruitment and education needed for rural and inner-city practice.

o   Programs like the University of Wisconsin School of Medicine and Public Health’s Wisconsin Academy of Rural Medicine (WARM) and TRaining In Urban Medicine and Public Health (TRIUMPH) acknowledge the uniqueness of rural and inner city practices.  Investments in expanding the pipeline needs we must support programs that emphasize recruitment from and training in these target communities.

o   The expansion and/or reallocation of resources that currently go into Graduate Medical Education needs to be made more flexible so as to include both new rural training tracks and rural rotations.

Make Workplace Wellness and Healthy Communities a National Priority

·      Reform must help individuals and communities to become healthier, to not need as much health care. Rural patients face the most daunting of health care challenges: they are older, poorer and sicker.  Rural America is less healthy due to too much smoking, drinking and eating, and too little exercise, education, jobs and income.

o   Healthcare reform must address factors unique to the rural context. It should lay down a road map to make our communities healthy. Prevention and Wellness provisions must present a comprehensive policy designed to ensure that all Americans will receive the state-of-the-art in both clinical and community preventive services, undertaking a coordinated effort to make comprehensive prevention research, evaluation, and delivery a permanent part of the national landscape.

o   Eliminate cost-sharing on recommended preventive services delivered by Medicare, Medicaid, and insurance available in the Health Insurance Exchange.

o   Support incentive models to stimulate multi-sectoral action toward community health improvement such as the University of Wisconsin’s Mobilizing Action Toward Community Health (MATCH). As repeatedly noted by the UW’s Population Health Institute, our health status is affected by multiple determinants beyond Health Care which also need to be addressed: Health Behaviors, Socioeconomic Factors and the Physical Environment.

II. Key Threats to Rural Health in Current Congressional Reform Proposals

Failure to Recognize and Incent High Quality and Appropriate Utilization

·      Payment reform must be built on quality of outcomes and efficiency of delivery, not simply historic cost and utilization data. Parts of the country, such as the Upper Midwest, should be rewarded, and not penalized, for developing systems of care that have led to Medicare per beneficiary spending that is consistently in the lower quartile for the country and Medicare quality measures place care to beneficiaries in the upper quartile.

o   A “Value index” for Medicare payments that realigns payments towards better clinical outcomes, better patient care and higher patient satisfaction by rewarding those who provide health care in this manner. Ideally, this value indexing would be built into payment formulas to help align incentives for all providers towards better care at lower costs. Recently, Rep. Ron Kind introduced a value-indexing payment proposal (HR 2844) for physicians; a similar approach is needed for hospitals, sensitive to the rural context and based on rural relevant metrics. We very much appreciate that both of Wisconsin’s Senators have cosponsored the companion bill (S. 1249) introduced by Senator Klobuchar.

Assuming that Medicare Payment Levels Can Sustain the Rural Health Safety Net

·      Any proposal that calls for provider reimbursement in a public plan to be the same as under Medicare would be a disaster for rural providers, inclusive of those who receive “cost based reimbursement.” Non-governmental payers provide the funds to make up for the cost of inpatient, outpatient and community services not recognized in the Medicare cost report, but which are necessary for the long-term ability of a provider to remain strong. Medicare does not recognize all costs necessary for operations. No organization can continue indefinitely without a reasonable positive operating margin as ultimately even non-profits must attract capital from private markets to sustain their work.

Congress Relinquishing It’s Role to the Medicare Payment Advisory Committee

·      Creating a coherent national strategy requires that individuals who understand rural health be at the table. The Medicare Payment Advisory Commission (MedPAC) is the major public forum for Medicare’s new payment and reporting strategies, but the rural perspective continues to be under represented.

·      Any proposal to increase the authority of the MedPAC board and elevate MedPAC into an outright policy or reimbursement setting board would be deeply concerning. We do understand the premise of this approach; however, we are concerned that MedPAC would hold significant power over setting Medicare payments and fees which would be unconstrained by any democratic forces (ie: an elected governing board, etc).

Experimenting with Bundled Payments in Rural Communities Without Prior Testing

·      The notion of “bundled payments” to CAHs and other small rural hospitals is a major concern in regards to the specifics and the potential for major unintended consequences. Our country could be poised to repeat a disaster similar to the misapplication over twenty years ago of Prospective Payment System demonstrations to small rural hospitals when that concept had only been tested in large urban hospitals. We believe that the rural safety net is too frail to experiment with it by applying reimbursement models with untested efficacy in the rural context. Rural relevant demonstration projects must precede the application of bundled payments to small rural hospitals.

·      The following cautions are from the Policy Brief “Rural Issues Related to Bundled Payments for Acute Care Episodes” by the Upper Midwest Rural Health Research Center (at the University of Minnesota), June, 2009:

o   Bundled payments may improve the quality of care in rural areas but the impact is likely to be unevenly distributed across geography and care systems.

o   Bundled payments may lead to greater provider consolidation and fewer provider options in rural markets.

o   Incorporating Critical Access Hospitals payment mechanism may be infeasible.

o   Under a bundled payment system, safeguards may need to be implemented to protect consumer choice and patient/provider relationships.

Readmission Rates and Penalties that Ignore the Limited Resources of Rural Communities

·      Penalties for higher than average hospital readmission rates will disproportionately and unfairly harm rural hospitals and communities. Rural hospitals often play a role different within the larger health care system then urban and suburban hospitals. Explicit consideration needs to be made for the less resource rich pre and post rural hospital environment.

o   According to the Upper Midwest Rural Health Research Center, “not all readmissions are preventable, but some may be prevented through the application of proven standards of care. Policymakers are increasingly focusing on this care dimension as a potential quality measure that can be linked to payment. Despite such significant potential impact, no research has examined the characteristics of and the extent to which these types of readmissions occur across categories of rural hospitals or by diagnoses of rural patient populations.”

Rural Providers Not Being Given a Fair Chance to Demonstrate the Quality of Their Care

·      Rural providers must be given the opportunity to demonstrate their quality of care and cost effectiveness through access to rural relevant metrics.  Providers must then actively participate in cooperative initiatives designed to drive improvement in our performance, rural and urban alike. Incentivizing participation would be the desired path.

o   Complicating the challenge of small numbers is the national context—a dysfunctional cacophony of measurement voices. There is an urgent need for agreement about what we measure and a coherent national strategy for quality accountability. We simply do not have the resources to waste addressing multiple versions of similar demands.

Inequitable Access to Capital for Health Information Infrastructure

·      CAHs need to receive full parity with respect to PPS hospitals for implementation of Health Information Technology. The American Recovery and Reinvestment Act of 2009 (ARRA) included billions of dollars in incentive payments to support hospitals, CAHs and PPS, in adopting Electronic Health Record (EHR) technology. Unfortunately, the final outcome created disproportionate incentives, with CAHs receiving only a moderate “bonus” payment for CAHs. We strongly believe full incentive payment parity should be provided to CAHs before expanding the pool of incentive payments to other recipients. The initial capital costs remain a barrier to implementation under the final CAH payment bonus.

·      Assure that the critically important thresholds for demonstrating “meaningful use” for CAHs and all other small rural hospitals be phased in. By phasing in reasonable and achievable requirements, we believe that 5 years from now it will be possible to look back and see significant improvement relating to both EHR adoption and quality for the vast majority of small rural hospitals.

·      If standards are set unreasonably high, without accounting for the current EHR adoption disparity between large and small hospitals, we believe the result will be that a minority of small rural hospitals will achieve the ‘meaningful use’ standards. The majority of small rural hospitals will be left behind, without any incentive payments and problems will be exacerbated with any financial penalties in the HIT initiatives under the ARRA legislation.

·      Onerous privacy provisions need to reflect a more balanced approach. Potential consent requirements and accounting of disclosure requirements create new administrative burdens and costs that would create a substantial barrier to the further adoption of EHRs.

Eliminating Rural Hospitals’ Key Justification for Tax-Exemption

·      Rural hospitals were created and are maintained in order to provide care locally. Any change in tax status would have a significant impact to their viability.  Rural hospitals provide significant charity care and other community benefits as defined by the IRS. But in addition, they provide a critically important community benefit which is not quantified in most national discussions of “community benefits.”

·      While most rural non-profit hospitals would meet any definition of community service, most definitions fail to acknowledge a non-profit rural hospital’s central purpose. Running a rural hospital has always been hard work given the uncertainty of patients’ needs from one day to the next, the higher rural costs of doing business and the perpetual challenges of recruiting professional staff.

“What is good for General Motors is good for the country.” We used to say that. But now it is more like “What is good for we Baby Boomers is good for the country.” In any event, this huge generation is aging into becoming patients. The tremors of this shift will hit our country for the next twenty years.

I am an aging “cheesehead” and proud of it. I know all too well Wisconsin’s justly famous beer, cheese and brats. But my primary care physician, workplace wellness program and a life event wacked me on the head. I am lucky. This dose of personal health reform has led to overdue lifestyle changes. Hopefully I will stay on track. Multiply my story by millions of fellow cheese heads and you see the bigger challenge.

Our workforce is getting older. Older workers are more likely to consume more health care as age and habits catch up with us. Poorer health, at any age, makes us less productive at work and increases our use of sick days. This costs employers more. More cost to employers make them less competitive. Being less competitive means fewer jobs for us and for our kids.

A recent report from the Council of Economic Advisors to President Obama drives this point home. “Slowing the growth in health care spending from 6 percent a year to 4.5 would have enormous benefits for the economy. It would create as many as 500,000 jobs a year and increase annual income for a family of four by $2,600.”

No amount of “healthcare reform” can fix our own behaviors. We must work to reduce the amount of care our system needs to deliver.

We must get serious about doing what we can to get and stay healthy. We need to do this as individuals, workplaces and communities.

We can speed up making healthy lifestyles a Wisconsin trademark. Rural has an extra challenge. There are 72 counties in Wisconsin. Most urban counties in Wisconsin are among the healthiest counties. Rural counties are often the least healthy. For the last five years, the Governor’s rural health council and the state’s two medical schools supported a Strong Rural Communities Initiative. Hospitals, public health agencies and employers worked together in six rural communities to help employees and their families become healthier. Changes in diet and exercise are encouraging and the work continues.

Wisconsin’s “Worksite Wellness Resource Kit” is a great free online resource for employers. Use Google to find it. The kit focuses on changing behaviors to reduce chronic diseases. Specific activities relate to health risk appraisals, physical activity, nutrition and tobacco use.

Many workplaces are working to help employees make healthier decisions. Employees are more likely to make healthier choices when workplace policies promote health and reduce risk of disease. Employee wellness committees are key to worksite success. All of us are more likely to respond when we hear clear expectations and are part of deciding how they can be met.

A new approach to workplace wellness is sponsored by Thrive. Thrive is a collaborative economic development enterprise for 8 counties in southern Wisconsin. Three dozen major healthcare organizations have developed a bold plan to improve the health of the region’s workforce. They are starting with themselves.

By 2011, the target is a 10 percent increase with those having formal wellness programs. The 3-year goal is a 10 percent improvement in employees choosing a healthier life style. The goal is to eat enough fruits and vegetables, be physically active, be at low or no-risk regarding alcohol and tobacco use. The 5-year goal is for 60 percent of workforce to be at a healthy weight.

These goals may seem too modest. But they are a major step towards making our region and our state a healthier place. We have started and hopefully more of Wisconsin will as well.

Readers not comfortable leaving a comment below may send feedback to: timsize@rwhc.com timsize@rwhc.com

Thanks to Louis Wenzlow, RWHC Director of Health Information Technology, who is the primary drafter and to other senior staff at RWHC who provided significant input. Download pdf or read below.

The American Recovery and Reinvestment Act of 2009 (ARRA) provides for Medicare incentive payments to hospitals that can demonstrate “meaningful use” of “certified EHR technology,” including for information exchange and for the submission of clinical quality measures, with definitions of these terms to be finalized by the Secretary of Health and Human Services (HHS). This paper provides a summary of published “Meaningful EHR User” definition recommendations, as well as the Rural Wisconsin Health Cooperative’s (RWHC) perspective on the issues. We also address the question of whether open source EHRs are necessarily the right fit for small rural hospitals. RWHC is a cooperative of 35 rural hospitals (including 28 Critical Access Hospitals) that promotes regional collaboration for health and health care services on behalf of rural communities.

Highlights from Other Associations’ “Meaningful EHR User” Recommendations:

College of Healthcare Information Management Executives (CHIME):

• Meaningful use must focus on outcomes and not mandate specific functionalities
• Phase in requirements without setting the bar too high, too early, but raise the bar over time
• Given existing obstacles, explore ways to initially exchange information other than through an HIE

The Markle Foundation:

• Primary goals need to be improving healthcare quality, reducing growth in costs, stimulating innovation, and protecting privacy; not the installation of hardware and software alone
• In the first years of implementation, meaningful use definition must optimize achievability for providers and benefits to patients and consumers, and the definition should expand over time
• Processes for certification should embed the capability for hospitals to attain meaningful use, to meet reporting requirements, and comply with security requirements
• Metrics should allow for a broad range of providers to participate
• Consumers, patients, and their families should benefit from HIT through improved and secure access

Healthcare Information and Management Systems Society (HIMSS):

• Recognize CCHIT as the certifying body for EHRs, and include Open Source and Best of Breed systems
• Publish data standards for output of EMR data, so interoperability requirements can be achieved
• Phase in criteria for meaningful use so there is reasonable time to manage the change

§ Phase 1 (2 years commencing 2011)

• Ancillary department systems (lab, pharmacy, radiology) and a clinical data repository are in use and interfaced to the patient accounting system. Electronic documentation of a variety of clinical information. CPOE and physician documentation are optional.
• Adoption of a combination of compliance metrics, including core measures, AHRQ quality outcomes and others
• Hospitals electronically exchange information via scanned/text documents, or XML

§ Phase 2 (2 years commencing 2013)

• 51% of orders entered electronically by physicians via CPOE. Electronic prescribing beyond the bounds of the hospital to external pharmacies for discharge medications
• Hospitals electronically exchange info with external entities using HITSP standards
• Additional QI metrics. Transmissions submitted in standardized, discrete data elements and transactions via the Continuity of Care Document (CCD)

§ Phase 3 (2 years commencing 2015)

• 85% of orders entered electronically by physicians via CPOE. Closed-loop medication administration at the point of care. Clinical decision support via evidence based order sets and core measures reminders. Analysis of pharmacokinetic outcomes
• Hospitals electronically exchange information with public health entities and HIEs which are connected at least at the state level
• Additional QI metrics. Components of health information, as specified in the CCD standard, are electronically exchanged as discrete data elements

RWHC’s “Meaningful EHR User” Definition Recommendations

1. CCHIT should be at least one of the certifying entities for EHRs, and certification should ensure that the certified product has the capabilities to allow hospitals to attain “Meaningful EHR User” designation:

• Rural and small hospitals have and will continue to rely on a certifying body to help assure that they have selected a vendor with appropriate capabilities. Since CCHIT establishment, many rural hospitals have selected CCHIT certified vendors with the understanding that such certification will be required to meet future regulations. Whether or not other certification mechanisms are established, the implicit commitment that CCHIT certification is meaningful should be upheld. Rural facilities cannot afford to completely reinvest in software, hardware, installation, and training costs based on shifting conceptions of what makes an appropriate certification body.

• CCHIT has so far struck a balance between large-hospital focused vendors and small-hospital focused vendors, with 4 of the 9 inpatient certified vendors commonly used by CAHs and other small hospitals

• To the extent that CCHIT certification standards do not force the vendors to provide capabilities that allow hospitals to attain “Meaningful EHR User” status, such standards should be added, and CCHIT should drive increasingly higher levels of capability in coordination with “Meaningful EHR User” definition phases, including for decision support, interoperability, reporting, and security. This concept is consistent with CCHIT’s current mission.

2. The information exchange requirement should be attainable by hospitals that are in states that do not have health information exchanges, and the cost and complexity of meeting the requirement should not be overly burdensome for small rural hospitals, which generally do not have any integration or interface expertise in house. Consistent with HIMSS recommendations, standards for output and input of EMR data, along with implementation guides, should be developed. Continuity of Care Document (CCD) exchange may be a good focus for this requirement. Vendor capability to produce the CCD should be driven through the CCHIT certification process.

3. Quality reporting metrics should be designed to maintain existing data submission efforts and to add those metrics that are relevant to quality and patient safety. Vendor capability to automatically capture and report on relevant statistics should be driven through the CCHIT certification process; but it should be understood that certain data, such as scanned documents or the data captured in physician dictations, will not be machine readable, so automated data capture and reporting will be initially limited. Automated quality submission statistics should be designed with a clear understanding of what will be machine readable after hospitals meet reasonable capability requirements of “meaningful use.” (See Section 5). The collection of non-machine readable relevant data should continue through the current abstraction and upload process.

4. The primary goals of achieving meaningful use should be improvements in quality and efficiency; however, it should be understood that sometimes quality comes at a higher cost, especially in smaller facilities where there is a lower and sometimes negative return on investment for clinical systems. While we agree that the installation of hardware and software alone is not the primary goal of achieving meaningful use, the migration from paper-based systems to digital systems that allow for decision support and better data collection is in our opinion a required step toward improved quality, as well as for healthcare reform. The critical issue here is to provide enough time for hospitals to phase in certified electronic systems so the hospitals’ existing workflow, quality, and efficiency challenges are mitigated as a result of the implementations.

5. Meaningful use capabilities should be clearly defined and phased in over time so they are reasonably attainable and so hospitals can appropriately address vendor selection, preparation, and the workflow and quality challenges discussed above. It should be understood that “critical access hospitals” (CAHs) and, separately, “rural” hospitals have a median adoption score of 1.1 on the HIMSS EMR adoption model, whereas “general medical surgical” hospitals have a median adoption score of 2.3. Given this, it seems likely to us that if the meaningful use capability thresholds are the same for CAHs and other small rural hospitals as they are for larger hospitals, far fewer small rural hospitals will attain meaningful use and qualify for incentive benefits.

This will likely exasperate the existing EHR adoption disparity between large and small hospitals. Also, if small rural hospitals are held to the same threshold standards, it is likely that they will have less time to devote to the workflow and quality aspects and will therefore have a higher rate of failed implementations. To address these issues, we recommend that “meaningful use” thresholds for CAHs and all other small rural hospitals be defined separately from thresholds for hospitals with more than 100 beds. Using the HIMSS phasing recommendation as a template, we recommend the following thresholds for CAHs and all other small rural hospitals with fewer than 100 beds:

§ Phase 1 (2 years commencing 2011)

• Ancillary department systems (lab, pharmacy, radiology) and a clinical data repository are in use and interfaced to the patient accounting system.

• A starter set of relevant core measures and other patient safety indicators to become incentivized rather than optional (as they currently are for CAHs). Since most data will still be paper based, continue QI data submissions through the current abstraction and upload process, but allow for automated reporting for the data that is available in machine readable form.

• Information exchange that is attainable without the need for significant increase in integration and interface expertise in house

§ Phase 2 (2 years commencing 2013)

• Electronic documentation of a variety of clinical information (allergies, care plans, vital signs, flow sheets, inputs and outputs, medication lists, etc.), such as through an electronic nurse documentation system. CPOE and physician documentation are optional.
• Expansion of relevant core measures and other patient safety indicators. Incentivized participation in staff and patient perception tools (such as H-CAHPS), which are currently optional for CAHs. With nurse documentation implemented, expand automation of reporting from the EHR.
• Information exchange that is attainable without the need for significant increase in integration and interface expertise in house

§ Phase 3 (2 years commencing 2015): Important to note that CAH benefit payments phase out after 2014, so this phase is only to avoid penalties. PPS hospitals that are meaningful users starting in 2013 will be receiving incentive payments through 2017.

• EMAR and clinical decision support via evidence based order sets and core measures reminders, with CPOE and physician documentation still optional.
• Demonstration and reporting of quality improvements relating to the selected indicators, and expansion of indicators to achieve additional patient safety goals.
• Information exchange that is attainable without the need for significant increase in integration and interface expertise in house

By phasing in reasonable and achievable requirements, we believe that five years from now it will be possible to look back and see significant improvement relating to both EHR adoption and quality for the vast majority of small rural hospitals. If standards are set unreasonably high, without accounting for the current EHR adoption disparity between large and small hospitals, we believe the result will be that a minority of small rural hospitals will achieve the “meaningful use” standards and earn their incentives, while the majority of small rural hospitals will effectively be left behind in the HIT revolution that ARRA represents.

RWHC’s “Certified EHR Cost” Definition Recommendations

Unlike PPS hospitals, CAHs get their bonus reimbursement based on what they spend on “Certified EHR.” We have not seen many weigh in on this definition, no doubt largely because bonuses for PPS hospitals do not depend on what they spend or the category of their expenditure.

We believe that for the CAH bonus (which is an expanded and immediately depreciable Medicare Share reimbursement for undepreciated and new certified EHR expenditures made by meaningful users between 2011 and 2014) to have much value, the definition of “Certified EHR Cost” should include software, implementation, hardware (server, desktop, laptops, tablets, carts for nurse documentation, etc.), infrastructure (such as networking equipment, including wireless), training, and other costs associated with building a successful, secure, and available EHR environment.

We also believe that the cost for PACS and other systems that are clearly part of the EHR and lead down the road to a paperless environment, should apply to the incentive bonus, even if they are not required for “meaningful use.” This will allow early adopter CAHs to innovate (beyond what is reasonable for most CAHs) and to get some benefit from the CAH incentive, just as PPS hospital early adopters will benefit through their incentive structure.

Our concern is that most of the categories of EHR cost identified above do not and likely will not have “certification” programs. Our recommendation therefore is that the concept “Certified EHR Cost” should be interpreted to mean “costs associated with developing a fully functional EHR environment that uses certified vendors in all those categories of cost where certification programs exist.”

RWHC’s Position Regarding “Open Source” Solutions for Rural Hospitals

We recommend a careful and deliberate approach to address the open source issue. Many advocates of open source (specifically OpenVista) are claiming that it is the right solution for small rural hospitals, primarily because it is assumed that OpenVista is a lower cost solution than commercial vendor solutions and because it has worked well at the VA. It is difficult to test these assumptions, since as far as we know OpenVista has never been fully implemented in an independent critical access hospital environment. Concerns regarding OpenVista in small hospitals include: (1) it was developed for a large hospital VA environment; how will that translate to the small independent hospital environment? (2) integrated financial applications are not available with OpenVista, as they are with commercial vendors; (3) the cost of installation and support may not scale to the very small CAH environment; (4) small hospitals do not have programmers that can take advantage of the open source nature of OpenVista; and (5) OpenVista is not CCHIT certified, even as four small hospital-focused commercial vendors are. Before significant dollars are spent to create a federal OpenVista offering, we recommend that the questions embedded in these concerns be answered through a thorough case study in which the costs, challenges, and benefits of OpenVista (in an independent CAH environment) are documented and compared to the costs, challenges and benefits of CCHIT certified small hospital-focused commercial vendor products.