A 'critical' win for Stage 2
When you picture the first handful of providers able to successfully attest to the rigors of Stage 2 meaningful use, a place like tiny Cottage Hospital might not be the first that leaps to mind.
Nestled on the forested border of New Hampshire and Vermont, the 25-bed critical access hospital was one of the first few to attest to Stage 2 in the first quarter of 2014.
Cottage has experience being at the head of the class. Back in 2011, it was the first critical access hospital in New England to attest to Stage 1. And it did so handily – for instance, it far surpassed the 30 percent minimum computerized provider order entry threshold, logging 70 percent of orders via CPOE.
But Stage 2, as most hospitals and providers are discovering, is orders of magnitude more difficult that Stage 1.
"I didn't really know what to expect when I came into it," says Rick Frederick, Cottage Hospital's chief information officer. "That said, I wasn't expecting the challenges that we did in fact encounter."
Nonetheless, he says, the hospital staff's approach to Stage 2 started with a promise to themselves.
"It began with the statement: 'We will achieve MU2,' says Frederick. "We were not going to have our software slow the process if we could avoid it. Fortunately our mandate came from the top at Cottage, and our vendor was just as committed to helping us achieve this goal."
That vendor, Medhost, specializes in serving small hospitals, and its integrated electronic health record – alongside its YourCareCommunity healthcare engagement platform and YourCareLink public health reporting tool – was critical to helping Cottage clear the many hurdles of Stage 2.
Not to say that all the proverbial ducks were in a row from day one, however.
"We started off with the specification and came up with a rough scope, and even though our vendor wasn't quite ready, the gaps were readily identifiable," says Frederick. "Fortunately, we were able to work together to close all these gaps."
Cottage Hospital CEO Maria Ryan, who's also an advanced practice RN, says the challenges were many – especially in the early going, when trying to pull the relevant patient data.
"We had a (business intelligence) tool … and the staff was doing all the right things," she says. "But with any new tool you have to keep looking at it, reevaluating it – why isn't it pulling the right data? It took time."
"For Stage 1, we needed less than one-tenth of that data," says Frederick, whose IT staff comprises just six FTEs. "This additional logging/processing dictated most of our need for more capable hardware. For Stage 2 it was a complete forklift upgrade of our core servers that handle the system."
As it has been for many hospitals, the 5 percent view/download/transmit threshold seemed especially daunting – especially for a hospital like theirs.
"Five percent of patients have to access their record electronically; how can you possibly make a patient do anything?" says Ryan. "Even though we're lucky at Cottage to have good bandwidth, we serve 13 towns in New Hampshire and 13 towns in Vermont and a lot of them are rural, and don't even have Internet. Also, our demographics are elderly."
So the hospital staff came up with a plan to inform each patient about the benefits of electronic access, assiduously taking down their email addresses as they prepared for discharge and walking them through the process of logging on and viewing their data.
"I think our plan was best practice and it worked for us," says Ryan.
As for another widely problematic measure – summaries of care for more than 10 percent of transitions and referrals – Cottage was already well positioned, she says.
"We've been sharing data with (area) doctors' offices for a while," she says. "They're all on different systems – one FQHC on the New Hampshire side is on Centricity, one on the Vermont side is on eClinicalWorks – but we'd been sharing data with them for a while. We were quite used to that. So to be able to send them the continuity of care document, it didn't seem that challenging."
There were some surprises along the way. Frederick, for instance, says CMS fine print tripped up the process at least once.
"There were some things I read in detail but it didn't quite register," he says. For example, "All the stuff you printed out had to have the vendor's logo on the document. I didn't recall reading that. Fortunately for us, Medhost was able to go back and rebuild those documents with the logo on it."
Medhost helped in many ways, says Ryan. "We've had a long history with our vendor. Our nurses were on electronic health records a decade ago. And we just recently moved forward with the physicians a little over a year ago. (Medhost has) had some changes in leadership and they've rebranded themselves, but they've really stepped up."
It didn't hurt, she adds, that "I have a world-class IT department. It's run by a great CIO who knows a lot about software and a lot about programming, so we were immediately respected. When (Medhost) was putting out a new product, they would come to Cottage and ask us to be a beta site. We were sometimes able to say, 'as a provider we don't think like that. Maybe a programmer might think like that, but hospitals are really complex and this is how we think as providers.' It was a really symbiotic relationship between us."
"Cottage Hospital proves that combining healthcare IT leadership and expertise with a deep clinical commitment can power facilities to significant operational and clinical accomplishments," said Craig Herrod, president of Medhost, in a press statement congratulating the hospital for its successful Stage 2 attestation.
Even as a tiny critical access hospital, Ryan says there are lessons larger organizations could learn from its example.
"You have to have the right people at the table," she says. "You have to have the clinical folks, the IT folks and your vendor – you've got to put a lot of pressure on your vendor and you've got to keep pushing forward."
Clinical buy-in was key. "Our informatics nurse set up an email address where people could write in their concerns, or call a number, and she would get back to everybody," says Ryan. "There was constantly communication happening. The medical staff had an IT component to it, and we had a hospitalist who was really heading things and able to teach it in that provider language."
Rigorous timelines are also critically important, she says. "Time passes so quickly. We're all wearing multiple hats. A project could easily slip away from you. You've got to have consistent meetings, and people have to be held accountable."
"It was Maria's mandate that we were going to attest to MU 2, and we did," says Frederick. "The support was up top. The investment was substantial, but the facility was behind it all the way. Not having that to battle with was a big win up front: Rather than going to the CFO and asking for a million dollars for hardware, it was more like, 'Here's what it will take.' And we just got it done."