Federal mandates are driving the work plans of most hospital IT efforts, especially in 2014. ICD-10, Meaningful Use, quality reporting, changing reimbursement and more are on the table, but healthcare delivery organizations have plenty of opportunity to innovate as well as cutting-edge advances to consider in their strategic planning.

“External programs are dictating big chunks of our agenda,” says Adam Wright, PhD, a medical informatician in the clinical informatics research and development group at Partners HealthCare in Boston. Once his team built their development agenda for the year, factoring in all the requirements, “there was not much space left for other activities.”

Ready or not…

ICD-10 is one of those requirements and survey after survey has indicated that the healthcare industry is lagging in its preparation for the Oct. 1 implementation date. The Centers for Medicare & Medicaid Services (CMS) have adamantly stated there will be no further delays. CMS will begin conducting testing with Medicare Administrative Contractors in March but other organizations have called for the agency to expand its external testing.

“ICD-10 is so much more than redoing coding fields and workflows,” says John D. Halamka, MD, CIO of Beth Israel Deaconess Medical Center in Boston. “There is a whole suite of projects that all relate back to ICD-10.” That could include implementation of computer-assisted coding and planning for (and preventing) recovery audit contractor (RAC) audits. Auditors are “going to look for levels of documentation to justify codes that don’t exist today,” Halamka points out.

Massachusetts is one state that has been working to alleviate the burden of ICD-10 on any one organization by creating a statewide collaborative testing program. Finding efficient ways to conduct testing is a challenge in many parts of the country, says Micky Tripathi, CEO of the Massachusetts eHealth Initiative. “Billing hinges on ICD-10. If you get that wrong, it could seriously affect your cash flow.” There is continued pressure from some organizations for a delay but Tripathi said he wouldn’t gamble on that possibility.

Plugging away at MU

Another outside force on healthcare organizations is the Meaningful Use (MU) program. “I’m hearing from some colleagues that they won’t bother with Stage 2 because ICD-10 will be so overwhelming,” says Halamka. The stimulus money and potential penalties aren’t enough to make the cost of the effort worthwhile, he explains.

Meanwhile, Tripathi says almost every hospital he knows is participating in MU Stage 2 on both the Medicare and Medicaid sides. The recent announcement of an extension, however, “is not a delay at all. It just delays when we move to Stage 3. It doesn’t take any of the pressure off.”

Those vendors who have yet to have their EHR products certified for 2014 will be scrambling, says Peter Basch, MD, medical director of ambulatory EHR and health IT policy for MedStar Health, based in Columbia, Md.

Demand for implementation services will increase, Basch predicts, “as providers and hospitals try to get upgraded to Stage 2-ready software early enough in the year to do sufficient testing such that they are able to successfully attest for Stage 2 in 2014.”

Aside from procuring the appropriate software, meeting the actual MU requirements will be a big focus this year. Interoperability is an important aspect of Stage 2 and “2014 should see the emergence—or lack thereof—of a sustainable business case for information exchange,” says Basch.

Also related to health information exchange (HIE), we’re starting to see progress in identity management, says John Mattison, MD, CMIO of Kaiser Permanente in southern California. One of the biggest challenges for HIE is the difficulty in assuring that the information exchanged is for the same person on both the sending and receiving ends. “Absent a solution that includes a really solid identity management process, flow of information in HIEs has not really reached its potential. Once we have a robust and accessible identity management solution, the volume of information exchange through HIE is going to skyrocket.”

Associated with the work underway to establish that more robust identity management solution is incorporating sent information into the receiving organization’s records, Mattison says. “We know with current standards and the consolidated CDA how to package information to send, but when that information is received, we’ve not yet invested sufficiently in the ability to unpack the information and put it into the receiving record chronologically.” Ideally, when providers review a chart that includes information from outside institutions, those data are “intermingled in ways that allow for providers to see a convenient and clear chronological course of events.”

‘More focus on CDS’

When considering emerging trends, Mattison predicts clinical decision support (CDS) will experience significant growth. “Just having information in digital form certainly makes it easier to have the information available at the point of decision-making. That’s a huge step forward in terms of quality.”

Although the industry is still in the very early stages for electronic records and CDS, the increased use of EHRs is going to put more focus on CDS, he says. “A lot of start-up companies and vendors are coming into the market with elegant and interesting CDS systems. The big opportunity in the near term is for the major EHR vendors to be more open in working with third-party decision support solutions and I think there’s a tremendous amount of innovation going on in that space.”

The foundation laid to date is very helpful as medical knowledge grows at a rapid rate, including genomics, proteomics and more. “The ability to have third-party CDS applications take advantage of multiple disparate sources of information is really important and an area of big change,” Mattison says.

He also sees a growing need for visualization tools “to help simplify the flood of information that is currently drowning physicians.” The human brain is better at processing information in the form of images but almost all of our information is represented in text and numbers, he says. Visual communications would help physicians “make better decisions and more rapidly incorporate large amounts of information.” This will provide providers with more confidence in the ability to use the information available and enable the sharing of information between patients and providers.
Analytics, patients, functionality

Wright expects a continuing emphasis on analytics. His organization is working on a new data warehousing project that will help “make sense of all these data we’re collecting and use it to provide higher quality, safer, more efficient care.”

The emphasis on patient engagement will continue to grow, Mattison says, and be increasingly important. Patient portals and personal health records will allow people to be more involved in their care. Incorporating information about what happens with patients between their hospitalizations and clinic visits is important, he says. “The key tools are mobile technology and sensor devices to fill in those gaps and create a much richer picture of what’s going on and almost certainly lead to opportunities for earlier detection, earlier intervention and better treatment.”  Emerging technology is advancing at an exponential pace, he says, leading to better collaboration capabilities.

Basch predicts an increase in functionality of patient portals and patient engagement-related applications. “Many providers and hospitals focused on meeting MU patient engagement thresholds may believe their existing platform and tools may be enough to ‘check the attestation boxes’  but that’s not compelling enough to help with attracting and retaining patients, or of leveraging their growing health IT infrastructure in quality or safety initiatives.”

Speaking of functionality, Mattison says there is a recognized gap between available and deployed functionality which continues to grow. “Closing the gap between what’s potentially available and what is actually implemented requires diligence, creativity and cultural change management to really drive more functionality into the hands of users. There’s an abundance of opportunity but clearly we’re lagging in the uptake.”

Shifting pay models

Again considering outside forces, payment changes have been happening for several years now and despite the radical redesign in reimbursement, Halamka says that’s not happening in a uniform way across the country. Although accountable care organizations (ACOs) are increasing, for example, growth is uneven according to a MedeAnalytics research report. There are about 300 commercial ACOs and more than 250 Medicare ACOs in operation but there are more such organizations in California, Texas, New England and Florida than in other regions.

“The whole system is moving to this new model but the reality is that it’s slowly moving and very spotty,” says Tripathi. Many organizations have contracts that cover different patients and offer different incentives, he adds. “IT systems need to enable people to effectively perform in each of those contract settings” which is particularly challenging because of the impact on revenue.

Wright agrees, saying changing payment models are “good but demanding on IT. If we’re at risk financially for our patients, we need better ways of measuring costs.” That means new technologies such as dashboards and registries because new care models require patients to be “continuously rather than episodically in touch with their doctor,” says Halamka.

Lyle Berkowitz, MD, associate chief medical officer of innovation for Northwestern Memorial Hospital in Chicago, believes that providers accepting risk will lead to major innovations in patient care. “Remote patient monitoring is a very hot area.” He also predicts much more in the way of mobile tools and telemedicine. Telemedicine “technology is easy, we just need to find the right business model.”

Automation could increase this year as well as we “start thinking about what parts of the healthcare system can and should be automated, from routine preventive care to reading radiology images,” Berkowitz says.

Team-based care has been on the rise and Berkowitz says the use of electronic protocols paired with EHR data will help route answers to routine workflows and tasks to the right person in an organization, creating faster and more consistent care, while freeing up time for the doctor to spend on more complex issues.  

The Affordable Care Act “in general creates a lot of turmoil in the market,” says Tripathi, such as deciphering new insurance products. He also notes that the new provision allowing for patients to choose not to disclose cash transactions is “easier said than done. How do you capture that information? It’s pretty complex with a lot of workflow changes right up to the registration desk.”

Another change that has a resounding ripple effect is the high rate of mergers and acquisitions in healthcare. More than $143.3 billion in healthcare mergers and acquisitions took place in 2012, according to a report from strategic advisory and investment banking firm Hammond Hanlon Camp. The number of transactions increased 6 percent to 1,063 deals, according to the report, and the firm predicts high levels of consolidation activity throughout this year and into 2014.
Such activity has “profound IT implications,” says Halamka.

There is little doubt that much of what happens in health IT in 2014 will have profound implications on the industry for some time to come.