Seven Steps to Stark and Meaningful Use

(… or helping your CIO get your CEO a raise)

Building relationships with unaffiliated community physicians is certainly a way to get your CEO’s attention. And really, how often does a CIO have the chance to actually enhance hospital admission rates? The closer a hospital’s relationships with unaffiliated community doctors, the more likely are those doctors to admit their patients to your hospital.

Just this week, CMS proposed extending the original Stark Safe Harbor, (which allows hospitals to provide EHR technology to unaffiliated physicians at 85% discounts) on providing EHR to physicians to the end of 2016 . For any hospital whose service area overlaps that of any other competing hospital, attracting independent physicians is as much a defensive as offensive move. Getting in the game is necessary before the unaffiliated doctors are captured by someone else or before they make their own investments in EHR. With the Stark Safe Harbor Extension, CMS is sending a signal that they expect your competitors to act.

The combination of Meaningful Use and other related compliance requirements and Stark Safe Harbor creates a “Perfect Storm” to put the creation of that strategy in the hands of hospital CIO’s. Quite frankly I’m a bit surprised more IT organizations are not proposing this concept to their executive boards as a method of achieving a competitive advantage. For any hospital already providing EHR technology to their own ambulatory physicians, the incremental effort is minimal compared to the potential benefits. Of course it is important to have an explicit strategy, and to operationalize the concept, but the tasks should be within the reach of most acute hospitals, and possibly even some Critical Access Hospitals affiliated with physician practices.

Pause for a moment, and reflect on what hospitals need to add in order to create an explicit EHR strategic relationship with unaffiliated physicians:

  1. Ambulatory EHR Technology
  2. An ability to track and coach EP’s on Meaningful Use and related compliance requirements
  3. New “subscription” contract templates
  4. An ability to offer physicians EHR technology at a discounted price
  5. Fundamental cost accounting, to calculate minimum EP bills
  6. A Sales Strategy Program to communicate the offer to targeted physicians or specialty groups
  7. An organization dedicated to supporting the EPs effective use of EHR technology.

Granted, this is not “effort free”, nor is it “risk free”. After all, physicians signing up to use your EHR will expect that as a result they will automatically achieve Meaningful Use, other compliance related requirements and will participate in sharing in the achievement of related bonuses and avoid penalties. They will also have an audit team to support them in surviving any CMS audits that may result. You may also find that the EPs that you would like to include simply dislike the EHR your provided, or the support you give them. But if your organization has a strategic approach to sourcing physicians, and an orientation toward providing diligent, high quality support services, the “Perfect Storm” of Stark Safe Harbor and Meaningful Use puts CIO’s into strategy management roles that enhance both hospital incentive optimization, penalty avoidance, and enhance personal careers. In fact, a comprehensive approach to enhancing compliance requirements can be leveraged to drive the organization’s overall performance.

The Seven Steps Explained

  1. Ambulatory EHR Technology – Physicians can only qualify for meaningful use stimulus payments, and the Stark Safe Harbor provisions, when Physicians use a software product certified by CMS as supporting ambulatory electronic health record functionality. At the time the original Stark regulations were created, there was no federal standard for certification, and the Safe Harbor provisions contained broad statements on what capabilities should exist. ARRA’s Meaningful Use creates a certification program, and provides a “super set” of requirements for both purposes.

  2. An ability to track and coach EP’s on Meaningful Use and other compliance requirements –ARRA created financial bonus incentives to physicians who use EHR in a manner defined by CMS as “Meaningful Use”. Meaningful Use has been introduced in Phases and the level of difficulty increases with each stage. In addition, CMS has added in quality measure reporting requirements for physicians (GPRO, PQRS, or registry reporting) that will either result in an incentive payment or a penalty. By now, all CIO’s know that simple ownership of EHR is inadequate to qualify physicians for ARRA Stimulus funds.   Most physicians do not hold sophisticated knowledge of compliance requirements, and may expect that since the hospital is providing a technology, each physician will automatically qualify to receive any applicable stimulus payments, and they will not be penalized or lose stimulus funds they have received. Today, CMS is actively auditing physician attestations for meaningful use, requiring proof that they have fulfilled all requirements. Failing an audit causes a physician to repay any stimulus funds they have received, or in some cases, to pay a penalty. Achieving these compliance stages as a group allows the risk to be shared and understood more fully by the EPs. If the hospital creates a knowledge center for physicians, it is a real value in the current healthcare environment.

    Hospitals providing EHR should also align resources to provide training, support measurement and documentation tools that assure physicians will qualify for, and retain their ARRA Stimulus, optimize incentives, and avoid penalties. Leaving the physicians “on their own” could actually damage the relationships the hospital is trying to develop.
  1. New “subscription” contract templates – A little bit of legalese will be necessary to document the relationship between hospital and each physician, or clinic regarding the EHR transaction. It seems prudent that this arrangement include hospital’s obligation for support, uptime and regulatory compliance. The contracts should also explain liability boundaries around achieving and sustaining Meaningful Use.

  2. An ability to bill physicians for discounted cost of EHR – physician recipients must pay at least 15% of the hospital’s cost of providing the ambulatory EHR. Hospitals will have flexibility in determining the payment mechanisms (one-time cost, annual subscription, other), but hospitals will be obligated to prove that the sum of the payments is within amounts required by the statute.

  3. Fundamental cost accounting, to calculate minimum EP bills – The Stark Safe Harbor provision allows for dramatic discounting of EHR software, but not hardware. “Information Technology or Training Services” are also covered by the Safe Harbor provisions (Federal Register /Vol. 71, No. 152 /Tuesday, August 8, 2006 /Rules and Regulations Page 45113, Column 3), so it seems prudent to have a methodology to isolate those costs (i.e., separate staff dedicated to implementation and support), should the hospital choose to provide such support.

  4. A Sales Strategy Program to connect with targeted physicians – Putting up a poster in the staff room will probably not reach all the physicians who admit to the hospital, much less those new providers you want to attract. If other hospitals are considering the same strategy, you may need to compete for physician attention. A comprehensive sales communication strategy will need to be developed and implemented to attract the desired physicians.

  5. An organization dedicated to supporting the EP’s use of EHR – Implementing EHR is a daunting and potentially expensive task. The technology is complex, the knowledge domain sophisticated, and clinical users are notoriously independent minded. Successful implementation requires well-defined plans and schedules geared to individual and small practices. But successful implementations also require the right balance between flexibility and standardization. Your implementation and training teams will need to provide their physician-side services outside patient hours. And you’ll have to define service level agreements similar to those used by third-party software hosting companies.

    While it may be tempting to create a support team under your IS department, this structure may not carry the appropriate message to these unaffiliated physicians. This structure is being developed to optimize business results, not to implement an IT system. If the ambulatory / unaffiliated support organization reports to a Provider Relations executive, or other clinical head, the community physicians using your EHR may perceive a higher level of service or a higher level of clinical content in the EHR. This organization should develop a deep understanding of the IT and EHR needs of small practices and compliance requirements and timeline. This type of support will be invaluable for physicians already burdened by many of the changes brought about by healthcare reform. For example, Meaningful Use requires a level of HIPAA documentation that is beyond the capabilities of most small offices. If you can assist them in implementing processes that mitigate this risk, they will appreciate the support. Providing understanding and assistance will cement the toughest of relationships.

Meaningful Use of EHR technology has created a buzz around EHR adoption, even in small physician practices. Take advantage of this unique point in time! And simply because some practices have acquired EHR technology does not take them away from your market. Many practices will choose poorly, implement poorly or dedicate inadequate resources to support and training. Those practices will ultimately be eager to accept a sophisticated, well organized offering … particularly when it communicates easily with your inpatient, lab and radiology environments.

Simply turning on an EHR for your community physicians is not enough. Deploying EHR technology without explicit help in getting unaffiliated EPs to Meaningful Use might actually damage relationships with some physicians who expect automatic compliance simply by using your HER. One insightful organization we have worked with uses Meaningful Use Monitor to communicate the nuances of requirements, disseminate education, monitor all compliance, and to assure that physicians will be able to survive the inevitable CMS audits.

Strategic-thinking hospitals will use this as an opportunity to create a powerful bond with otherwise unaffiliated physicians. Those hospitals who choose not to take advantage of the extended Safe Harbor provisions risk loss of unaffiliated physician populations to assertive competitors. Where competition exists, physicians will choose between options based not only on the merits of the EHR technology, but also concierge-type service levels, Meaningful Use and compliance support services, and affiliation with expert, top-shelf talent that can help them to weather the storm of healthcare reform successfully.