Optimism about meeting meaningful use fades for hospitals

Hospital chief information officers are less confident than they were only a few months ago about their ability to meet federal requirements for meaningful use of electronic medical records. The biggest obstacle, they say, is getting physicians to use computerized physician order entry systems.

A survey by the College of Healthcare Information Management Executives taken Nov. 8-22, 2010, found that 15% of the 191 CHIME members surveyed (representing 13% of the organization's membership) believed that their hospitals would have everything in place by Oct. 1, 2011, to get funding under meaningful use. That number was down nearly half from August 2010, when a CHIME survey found 28% of hospital CIOs were positive about meeting meaningful use by the same date asked in the later survey.

Only 11% in each survey said their facilities were unlikely to reach meaningful use guidelines. The shift in the survey came from those who thought their facilities would not meet meaningful use by Oct. 1, but would by Sept. 30, 2012, the end of the stage 1 deadline. In August 2010, that number was 61%. In November 2010, it was 75%.

Hospitals that meet meaningful use requirements under the Medicare or Medicaid incentive programs could receive at least $2 million in bonus pay. To do so, however, they must show that physicians are using CPOE systems in their hospitals. However, CPOE use in hospitals is not a standard for physicians to fulfill their own meaningful use requirements.

As a result, many hospital chief information officers are finding that physicians who resist technology and have little to gain financially from embracing it are sometimes slow to change.

Challenges expected

In the November CHIME survey, 62% of respondents said they "expect challenges regarding the implementation of CPOE to meet meaningful use objectives."

More than half of CIOs identified the biggest barrier to CPOE use as "getting clinicians to enter orders into their CPOE system." In CPOE, physicians type orders themselves, rather than writing a note or dictating others to do it for them.

Steven Waldren, MD, director of the American Academy of Family Physicians' Center for Health Information Technology, said: "This is one of the tougher areas for hospitals, especially for those that have physicians who are not staff employees. If they are staff employees, they can build into their salaries utilization measures to incent them."

Under the meaningful use rules, 30% of all unique patients with at least one medicine on their medication list need to have at least one medication ordered electronically. Pam McNutt, senior vice president and CIO of Methodist Health System in Dallas, said at first blush the requirement seemed reasonable. But to get to that 30% threshold, "you are rolling it out pretty broad anyways," she said.

Physicians' unwillingness to use CPOE did not start with meaningful use, said McNutt, who is also chair of CHIME's policy steering committee. "Physicians fundamentally think, 'For me to have to track down a computer or to get a handheld device or take something around with me and sit there and enter orders is not as convenient as having a clipboard and prescription pad,' " she said.

Dr. Waldren said the time aspect that McNutt referred to also affects a physician's ability to make money. "A lot of the physicians are paid on a per-day or per-visit basis in the hospital, and anything that takes more time for them to have to go through where they don't see there's added value makes it a challenge for docs to want to do that."

McNutt said Methodist is a mixed environment of some physicians using CPOE and others who aren't. She said the hospital system had no choice but to go with a mixed environment, because it knew achieving 100% compliance was not possible.

One success story

However, she pointed to a hospital system that successfully achieved high CPOE adoption rates among its affiliated physicians, without a mandate.

Ferdinand Velasco, MD, vice president and chief medical information officer for Texas Health Resources, said that by making a special effort to get physicians to use CPOE, the system is at a 99% adoption rate.

As a chain of 13 community hospitals that has no significant resident population, Dr. Velasco said Texas Health approached CPOE use the same way it approached EMR adoption -- partnering with physicians.

He said physicians were involved from the onset, helping to pick out a system and develop training programs. CPOE use at each location was never made mandatory initially. The hospitals waited for a critical mass, which has taken less time at each location, before making it mandatory, Dr. Velasco said. In most cases, physicians make the decision to go mandatory.

McNutt agrees that getting physicians involved in the process from the beginning is important. But hospitals that already have implemented a system will have to find another way to woo them.

Dr. Velasco said it's important for physicians to realize that CPOE use benefits the patient, not the hospital. It improves patient safety and reduces the time they wait for the medications they need.

Dr. Waldren said hospitals also can work with doctors to tweak the systems in a way that matches their workflow. He said if hospitals can find the doctors on staff who see the value, they can use them to help educate others.