Impacts of EHR Certification and Meaningful Use Implementation on an Integrated Delivery Network

Abstract

Three years ago Intermountain Healthcare made the decision to participate in the Medicare and Medicaid Electronic Heath Record (EHR) Incentive Program which required that hospitals and providers use a certified EHR in a meaningful way. At that time, the barriers to enhance our home grown system, and change clinician workflows were numerous and large. This paper describes the time and effort required to enhance our legacy systems in order to pass certification, including filling 47 gaps in (EHR) functionality. We also describe the processes and resources that resulted in successful changes to many clinical workflows required by clinicians to meet meaningful use requirements. In 2011 we set meaningful use targets of 75% of employed physicians and 75% of our hospitals to meet Stage 1 of meaningful use by 2013. By the end of 2013, 87% of 696 employed eligible professionals and 100% of 22 Intermountain hospitals had successfully attested for Stage 1. This paper describes documented and perceived costs to Intermountain including time, effort, resources, postponement of other projects, as well as documented and perceived benefits of attainment of meaningful use.

Introduction

In the U.S. over 89% of 5011 eligible hospitals and over 66% of 527,200 eligible professionals have received an incentive payment from the Medicare and Medicaid EHR Incentive Program, which stems from the Health Information Technology for Economic and Clinical Health Act (HITECH), and American Recovery and Reinvestment Act (ARRA) of 2009.¹ Over 20 Billion dollars of incentives have been distributed for healthcare information technology (HIT) projects to accelerate the adoption of EHRs and other technology, and to have the technology used in a meaningful way². Intermountain Healthcare eligible hospitals (EH) and eligible professionals (EP) were eligible for approximately $35 million in incentives from Medicare and Medicaid for the first year of Stage 1 of the incentive program in 2013. $28M was estimated for our hospitals and $5M for our ambulatory providers.

A paper presented at the AMIA proceedings in 2011 described the decision to move forward with meaningful use and outlined the gaps and challenges that faced Intermountain Healthcare for this endeavor.³ Because our EHR at Intermountain was self-developed, we had to certify our EHR prior to meeting meaningful use to meet the requirements outlined in the EHR Standards rule³ and related National Institute of Standards and Testing (NIST) Approved Test Procedures for certification.⁴ We identified 20 functionalities that needed no modification, but 47 requirements which required some enhancement or completely new development in order to pass certification. See Table 1.

Table 1.

EHR Functional Gaps - 2011

Care Site	Modular System	Functionality Category	Later Removed
Ambulatory	HELP2	Automate measure calculation (ambulatory)
Ambulatory	HELP2	Electronic prescribing
Ambulatory	HELP2	Maintain up-do-date problem list
Ambulatory	HELP2	Patient-specific education resources
Ambulatory	HELP2	Submission to Public Health Registries
Ambulatory	HIE	Clinical summaries
Ambulatory	HIE	Exchange clinical info and summary report
Ambulatory	Centricity Business	Access control
Ambulatory	Centricity Business	Audit log
Ambulatory	Centricity Business	Authentication
Ambulatory	Centricity Business	Automatic log-off
Ambulatory	Centricity Business	Emergency access
Ambulatory	Centricity Business	Encryption when exchanging EHI
Both	HELP2	Access control
Both	HELP2	Audit log
Both	HELP2	Authentication
Both	HELP2	Automatic log-off
Both	HELP2	Computerized provider order entry
Both	HELP2	Emergency access
Both	HELP2	General Encryption
Both	HELP2	Integrity
Both	My Health Portal	Audit log
Both	My Health Portal	Authentication
Both	My Health Portal	Emergency access
Both	EDW	Clinical Quality Measures
Hospital	ECIS	Audit log	x
Hospital	ECIS	Emergency access	x
Hospital	ECIS	Maintain active medication allergy list	x
Hospital	ECIS	Maintain up-do-date problem list
Hospital	ED System	Audit log
Hospital	ED System	Calculate BMI
Hospital	ED System	Emergency access
Hospital	ED System	Maintain up-do-date problem list
Hospital	ED System	Smoking Status
Hospital	ED System	Vital Signs
Hospital	HELP1	Audit log	x
Hospital	HELP1	Automate measure calculation (Hospital)	x
Hospital	HELP1	Calculate BMI
Hospital	HELP1	Computerized provider order entry	x
Hospital	HELP1	Emergency access	x
Hospital	HELP1	Smoking Status	x
Hospital	HELP1	Submission to Public Health Registries
Hospital	HELP2	Patient-specific education resources
Hospital	HIE	Electronic copy of discharge instructions
Hospital	HIE	Electronic copy of health information
Hospital	HIE	Electronic copy of health info (d/c summary)
Hospital	HIE	Exchange clinical info summary record

We also reviewed the CMS Incentive Program Rule⁵ to understand the Stage 1 requirements necessary to meet meaningful use in the ambulatory and hospital settings. Our workflow analysis identified 10 meaningful use workflows that we projected would require change to clinician workflow to bring all of our hospitals and ambulatory providers above the required thresholds. These workflows were identified as Problem List (hospital and ambulatory), Medication Allergy List (hospital and ambulatory), Computer Provider Order Entry (CPOE List hospital and ambulatory), Smoking Status List (hospital and ambulatory), Patient Education List (hospital and ambulatory), Electronic Prescribing (ambulatory only), and Timely Access to Health Information (ambulatory only). See Table 2.

Table 2.

Meaningful Use Status 2011 – Workflow Challenges

Final Meaningful Use Stage 1 Objectives	Measure Requirement Threshold	Percent of Providers that Meet Measure	Number of Hospitals that Meet Measure out of 22
Use Computerized Provider Order Entry (CPOE)	30%	55%	18
Electronic Prescribing [EP only]	40%	5%	N/A
Problem List	80%	20%	None
Medication Allergy List	80%	45%	5
Smoking Status	50%	20%	19
Timely Electronic Access to Health Information [EP Only]	10%	20%	N/A
Patient Specific Education	10%	50%	None

Our 2011 analysis demonstrated that we had significant work to do to close the EHR functional gaps and the meaningful use gaps. We divided the work into three major projects; EHR certification, led by our Information Systems (IS) division, hospital meaningful use implementation, and ambulatory meaningful use implementation. Intermountain made reaching meaningful use a board goal for our system, giving the project top 3 status in our list of enterprise projects. This decision by leadership allowed all three project teams to obtain the staffing and clout to mobilize to meet the challenge. Projects prioritized lower were postponed to allow for the meaningful use project to move forward. Likewise, the Intermountain Medical Group of ambulatory physicians and the 22 hospitals prioritized meaningful use highly, making it a board-level goal for their organizations.

Methods

This analysis was performed at Intermountain Healthcare, a not-for-profit integrated health care delivery network which operates 22 hospitals (130,000 admissions per year), employs over 900 physicians working in 170 ambulatory clinics. Intermountain’s clinical information systems have been described previously.^7,8 We currently use two home-grown, legacy clinical information systems, HELP in the hospitals and HELP2 primarily in the ambulatory setting. Over 13,500 unique users access HELP to retrieve results and/or document care for over 123,000 patient records per month. Over 13,000 clinicians use the HELP2 EHR each month to access records or document care on over 260,000 unique patients. Providers access different modules for different functionality, including documentation of progress notes, problem lists, medication orders, nursing documentation, etc.

Developing EHR Functionality for Certification

We assembled twelve teams and divided all of the Stage 1 EHR NIST requirements that required enhancement or creation among the teams. These functions are shown in Table 1. Each team consisted of a team lead analyst, programmer, informaticist, terminology analyst, quality assurance analyst, certification analyst and often an interface analyst. These teams reported to a project manager, and certification lead. The project was prioritized at number 1 or 2 in IS during 2012 and 2013

Achieving Meaningful Use

Intermountain formed the Meaningful Use Steering Committee (MUSC) to oversee the goal of attaining meaningful use in our Intermountain Medical Group (IMG) of employed physicians and in our 22 hospitals. This committee included VP level physician and nursing executives, certification lead, project manager, informaticist, MU Initiatives Manager, and regulatory advisor from the IMG and hospital system. The team met weekly and could escalate urgent issues to the Chief Information Officer, Chief Medical Officer, and Chief Nursing Officer for assistance in prioritization for resolution. Each Hospital and IMG regional champion formed Meaningful Use working groups that were responsible for setting and tracking meaningful use goals. These working groups consisted of regional physician and nurse champions, regional nursing consultants, and clinical systems specialists to train on and track meaningful use goals. Meaningful Use metric dashboards with drill-down capability were created for hospitals and IMG regions and clinics and were monitored for progress and/or issues by the MUSC.

Hospital working group tasks included education of the hospital leadership about meaningful use, assembling local teams representing nursing, physicians, information systems, finance, regulatory compliance, and health information management - medical records (HIM). These teams met to review requirements and reinforce or establish workflows to meet the meaningful use targets. Departments with deficiencies in particular areas, such as Problem List or CPOE were encouraged to adopt successful workflows that were in place in other Intermountain locations. Expectations were set by local leadership to stress the importance of compliance with the meaningful use measures.

The IMG ambulatory physicians working groups worked with clinical systems specialists and clinic managers to identify workflow deficiencies, then to modify and improve these workflows. Yearly provider incentives (15% of base pay) were based partially on whether a provider reached meaningful use.

Objective Impacts

All information system team members tracked their time for function development and certification-related tasks in project management software. This time tracking data as well as resource hourly rate was stored in our enterprise data warehouse (EDW) and converted to a data cube for analysis in order to determine time and dollar cost for the EHR certification project. Work-in-progress (WIP) Actual amount in dollars is defined as the WIP times an FTE rate, which is a normalized FTE rate by role. Ambulatory and hospital meaningful use team leads estimated time and effort project tasks by resource group to achieve meaningful use. Hourly rate for meaningful use project team roles was derived from an average of rate by role taken from Intermountain human resources records.

Workflow changes were tracked by following changes in meaningful use automated measure metric values, e.g. percent of a hospital’s patients that had a coded problem on their problem list. These metrics, along with clinical quality measure (CQM) measures were generated weekly for all providers and hospitals and stored in our EDW. Total dollar incentive payments received for successful attestation for all providers and hospitals from Medicare and Medicaid were tabulated.

Subjective Impacts

Subjective impacts of the EHR certification and Meaningful Use project, both negative and positive, were elicited from information system, hospital, and physician executive leadership. Clinical leadership was asked about the financial and reputational impact as well as impact on patients, physicians/nurses and ancillary staff. Information systems product managers were asked whether the EHR certification and Meaningful Use project had important impacts such as promotion or demotion of other projects.

Results

Objective Impacts

The total hours and estimated costs to achieve Stage 1 EHR certification for outpatient and inpatient systems are shown in Table 3. Total hours were 221,765 between 2011 and 2013 and estimated costs came to $12.2M.

Table 3.

EHR Certification Expenditures

	2011		2012		2013		2011–2013
IS Systems	WIP Actual HRS	WIP Actual AMT	WIP Actual HRS	WIP Actual AMT	WIP Actual HRS	WIP Actual AMT	Total WIP Actual HRS	Total WIP Actual AMT
CPOE	6,671	$ 339,345	29,904	$ 1,715,264	34,139	$ 2,022,520	70,762	$ 4,127,129
HITECH	2,384	$ 144,385	8,324	$ 481,563	6,091	$ 360,312	16,797	$ 936,759
ANCILLARY	7,988	$ 438,193	26,750	$ 1,487,836	21,950	$ 1,197,713	56,687	$ 3,123,741
HELP1	4,532	$ 230,780	13,759	$ 692,220	12,264	$ 634,661	30,554	$ 1,557,662
HELP2	5,132	$ 264,077	19,147	$ 995,114	22,636	$ 1,173,950	46,965	$ 2,433,141
Totals	26,708	$ 1,466,780	97,885	$ 5,371,997	97,179	$ 5,389,655	221,765	$ 12,228,432

The total hours and estimated costs to meet and attest for Meaningful Use for hospitals are show in Table 4 and for eligible professionals in Table 5. Respectively, these totals were $3.43M and $1.67M totaling $5.1M.

Table 4.

Hospital Meaningful Use Expenditures

Intermountain EH		2011			2012			2013
EP or EH	FTE Type	Number FTEs	average % of annual time on MU	Estimated Cost	Number FTEs	averag; % of annual time on MU	Estimated Cost	Number FTEs	average % of annual time on MU	Estimated Cost
EH	MU Business Lead	1	30	$ 27,000	1	30	$ 27,000	1	20	$ 18,000
EH	Medical Informaticist	1	60	$ 54,000	1	50	$ 54,000	1	30	$ 27,000
EH	MU Initiatives Manager	1	90	$ 81,000	1.5	90	$ 121,500	2	65	$ 117,000
EH	MU Regional Champions	12	20	$ 216,000	12	20	$ 216,000	20	15	$ 270,000
EH	MU Subject Matter Experts	3	15	$ 40,500	4	15	$ 54,000	5	5	$ 22,500
EH	Clinical Systems Specialists	22	10	$ 198,000	22	40	$ 792,000	22	40	$ 792,000
EH	MU Reports (not in IS or EDW]	2	40	$ 72,000	3	40	$ 108,000	3	30	$ 81,000
EH	Privacy/Security/Regulatory	1	15	$ 13,500	1	15	$ 13,500	1	5	$ 4,500
EH	Finance	1	5	$ 4,500	1	5	$ 4,500	2	2	$ 3,600
		44		$ 706,500	46.5		$ 1,390,500	57		$ 1,335,600
										$3,432,600

Table 5.

Eligible Professional Meaningful Use Expenditures

Intermountain EP		2011			2012			2013
	FTE Type	Number FTEs	average % of annual time on MU	$	Number FTEs	average % of annual time on MU	$	Number FTEs	average % of annual time on MU	$
EP	MU Business Lead	1	50	$ 45,000	1	50	$ 45,000	1	40	$ 36,000
EP	Medical Informaticist	1	80	$ 72,000	1	80	$ 72,000	1	80	$ 72,000
EP	Training Regional Nurse Consultant			$ -	8	20	$ 144,000	6	20	$ 144,000
EP	Clinical Systes Specialists	3			5	50	$ 225,000	5	50	$ 225,000
EP	MU Attestation Lead	1	0	$ -	1	80	$ 72,000	1	80	$ 72,000
EP	MU Attestation Proxies			$ -	9	10	$ 81,000	9	10	$ 81,000
EP	IMG MU Reports			$ -	2	25	$ 45,000	2	50	$ 90,000
EP	MU Subject Matter and Workflow Experts	1			3	10	$ 27,000	4	10	$ 36,000
EP	Privacy/Security/Regulatory	1	20	$ 18,000	2	10	$ 18,000	2	10	$ 18,000
EP	Finance	1	10	$ 9,000	1	10	$ 9,000	1	10	$ 9,000
EP	Other			$ -			$
		9		$ 144,000	33		$ 738,000	34		$ 783,000
										$1,665,000.00

608 of 696 (87%) outpatient eligible professionals (EP) successfully attested for meaningful use in 2012 for Stage 1, year 1. The incentives received professionals are shown in Table 6. Total incentives received for Stage 1, year 1(2012) and projected for year 2(2013) are $17.2M.

Table 6.

IMG Ambulatory Provider (EP) Incentives

IMG Provider Grouping	Number of Providers 2012	Incentives Received 2012	Number of Providers 2013	Projected Incentives 2013
IMG Providers (Physicians & Mid-Levels)	1090		1342
IMG Providers who are EPs	696		746
IMG Providers Attested	629		729
IMG Providers Attested(processed) successfully	60S	$9.2M	679	$8M

All 22 Intermountain hospitals successfully attested for Stage 1 year 1 in fiscal year 2013. The incentives received and pending for hospitals are shown in Table 7. Received payments totaled $19M. Pending payments total $9.6M.

Table 7.

Hospital Stage 1, Year 1 Incentives 2013

Faciltiy Name	Medicare Incentive	Date		Medcaid Incentive	Date
Alta View	$ 975,783	31-Dec		$ 305,730	28-Feb
American Fork	$ 1,058,743	31-Dec		$ 493,712	7-Mar
Bear River	$ 470,792	31-Dec		$ 397,475	7-Mar
Dixie	$ 1,810,081	31-Dec		$ 697,000	PENDING
Garfield	$ 910,616	31-Dec		$ 192,000	PENDING
IMED	$ 2,363,523	31-Dec		$ -
LDSH	$ 1,029,818	31-Dec		$ 750,000	PENDING
Logan	$ 593,134	31-Dec		$ 623,000	PENDING
MKD	$ 2,424,138	31-Dec		$ 893,000	PENDING
Orem	$ 8,213	31-Dec		$ 20,000	PENDING
Park City	$ 602,896	31-Dec		$ -
Riverton	$ 397,890	31-Dec		$ 475,000	PENDING
Sevier	$ 958,048	31-Dec		$ 381,000	PENDING
TOSH	$ 865,842	31-Dec		$ -
UVRMC	$ 1,737,077	31-Dec		$ 1,356,000	PENDING
Valley View	$ 1,056,146	31-Dec		$ 589,000	PENDING
Fillmore (CAH)	$ 57,000	PENDING		$ 360,000	PENDING
Heber (CAH)	$ 138,000	PENDING		$ 417,000	PENDING
Sanpete (CAH)	$ 150,000	PENDING		$ 571,700	28-Feb
Cassia (CAH)	$ -			$ 459,141	31-Dec
Delta (CAH)	$ -			$ 446,000	PENDING
PCMC	$ -			$ 2,094,000	PENDING
received	$ 17,262,742		received	$ 2,227,758
pending	$ 345,000		pending	$ 9,293,000

For Stage 1, through 2013 EP (year 1 and year 2) and EH (year 1) received and pending incentives totaled $46.3M. Total costs for EHR certification and meaningful use implementation and attestation were $17.3M.

We identified certain meaningful use clinician workflows we anticipated would be challenging. Meaningful Use could only be achieved by an EP or hospital if all measures were met. These challenging workflows, with before and after results, are shown in Table 8. For instance, only 55% of EPs met the CPOE measure at the beginning of Stage 1. By the end of Stage 1 attestation period, 100% of providers met the CPOE measure.

Table 8.

Workflow Challenge Results, Before and After Stage 1 Implementation

Meaningful Use Stage 1 Objectives	Measure Requirement Threshold	Percent of Providers that Met Measure BEFORE	Percent of Providers that Met Measure AFTER	Number of Hospitals that Meet Measure out of 22 BEFORE	Number of Hospitals that Meet Measure out of 22 AFTER
Use Computerized Provider Order Entry (CPOE)	30%	55%	100%	18	22
Electronic Prescribing [EP only]	40%	5%	94%	N/A	N/A
Problem List	80%	20%	84%	None	22
Medication Allergy List	80%	45%	94%	5	22
Smoking Status	50%	20%	99%	19	22
Timely Electronic Access to Health Info [EP Only]	10%	20%	85%	N/A	N/A

Subjective Impacts

Information system leaders commented that some important projects were delayed by EHR certification and meaningful use. These included replacement of legacy system functionality in labor and delivery, electronic consent handling, Clinical Health Information Exchange workflow integration, Exchange Provider Directory, enterprise provider master replacement, and replacement/enhancement of inpatient CPOE functionality (vs emergency department CPOE, which was used for meaningful use). IS leadership did mention that some projects were accelerated due to the meaningful use project including CPOE in the Emergency Department, and E-prescribe functionality.

Clinical leadership from the IMG and hospitals both agreed that there was reputational benefit from achieving meaningful use. In addition, they agreed on the benefit of the incentives and potential avoidance of future penalties. IMG leadership felt that patient engagement was likely improved after meaningful use, and was neutral on patient safety and patient satisfaction. Hospital leadership was neutral on the question of patient engagement, patient safety, and patient satisfaction. Both hospital and IMG leadership had feedback that physician and nurse productivity was negatively impacted. The IMG and hospital leadership also felt that clinic and emergency department (ED) physician, ED and clinic nurse, and clinic ancillary staff satisfaction was negatively impacted, due to the extra work necessary to meet meaningful use.

Discussion

This evaluation covers two very large projects at our institution; EHR enhancement/certification and EHR implementation at clinics and hospitals in order to meet meaningful use. This is by no means a comprehensive summary and evaluation of these two projects. However, we do describe with some objective and subjective information, some preliminary findings that inform the cost and benefit proposition for the EHR Incentive Program. The availability of detailed project information such as tasks, time, and resources for both the EHR enhancement/certification effort, and for the organizational work to meet meaningful use both in the outpatient and inpatient setting was very informative to us. We also tracked growth in EHR function usage, such as CPOE, E-prescribe, and Problem List throughout the clinics and hospitals as a result of the meaningful use requirements. Our study had several limitations. We did not track the impact/cost of the workflow changes to clinicians (such as time nor effort spent). Nor did we formally survey all the clinicians about workflow changes and satisfaction.

The decision to certify our EHR and meet meaningful use for Stage 1 use was a success from a strictly financial perspective. However, the true cost and benefit to the organization is not yet completely understood. We can see that the use of the EHR functions that are prescribed by meaningful use has grown. However, this is balanced with preliminary subjective feedback from clinicians that feel that patients may be more engaged, while these same clinicians are feeling less productive and less satisfied. Further analysis on the impact of the EHR incentive program is needed to shed light on this dilemma. Meanwhile, the Stage 2 requirements and workflows are looming.

Conclusion

This paper describes the experience and some preliminary impacts resulting from EHR certification, implementation, and successful attestation for meaningful Stage 1 at Intermountain Healthcare.