Smaller hospitals may benefit from this affordable strategy.


In September 2011, NorthCrest Medical Center near Nashville became the first hospital in the nation to use an emergency department information system (EDIS) to qualify for Medicaid incentive payments under the federal HITECH Act. The 109-bed, not-for-profit community hospital, ranked by the Joint Commission as one of the nation's top performers on key quality measures, was able to take the alternative approach to demonstrating meaningful use of an electronic health record (EHR) thanks to its use of Allscripts ED, the only ED system certified for use under HITECH as a “Complete EHR.”

Although NorthCrest has an inpatient EHR system, smaller community and critical access hospitals (CAHs) that are unable to afford a full inpatient system could emulate NorthCrest's strategy to demonstrate meaningful use with an EDIS and save millions of dollars, says Randy Davis, senior vice president and chief information officer of NorthCrest. According to a 2010 report by the University of Minnesota Rural Health Research Center, 97 percent of the nation's 1,400 CAHs have yet to adopt an acute care EHR that would qualify for HITECH payments because they lack the necessary financial resources. 

Davis recalls the moment he realized NorthCrest could use its EDIS to demonstrate meaningful use. “I was taking the HIMSS Analytics survey about how to qualify for meaningful use and I saw very quickly that we were already doing all of this in the ED or had it in the works,” he says. “We were already in the high-90th percentile in compliance with meaningful-use Stage 1 requirements without changing a thing. In preparing to attest, I don't believe the physicians even noticed because we did not make any significant changes to their workflow.”

In December 2010, CMS clarified that hospitals that have not installed an inpatient EHR can still demonstrate meaningful use with information drawn from a system more commonly used as an EDIS, as long as it is certified as a “Complete EHR.” Using the “All ED Visits Method” for demonstrating meaningful use, hospitals can measure quality results for patients treated and discharged directly from the ED, in addition to the previously approved method of measuring patients who are admitted to an inpatient department or provided observation services after being treated in the ED.

NorthCrest first implemented its EDIS in 2001, primarily to reduce patient length of stay (LOS) while maximizing resources in the face of a nursing shortage that continues to this day in Tennessee. The strategy worked; today NorthCrest's ED patients can expect to be treated or transferred within two hours and 20 minutes of walking through the door, an hour under the national average. Davis credits the EDIS with helping the hospital accomplish the change without adding FTEs. “Only through use of electronic systems like the ED tracking board are you able to maximize resources to that degree,” Davis says.

After receiving a meaningful-use incentive check from Medicaid, NorthCrest began its 90-day attestation period to meet the more stringent Medicare meaningful-use requirements in October. Davis wants to meet the Medicare requirements in 2011 so that NorthCrest will have until 2014 to meet the Stage 2 requirements for meaningful use.

The hospital so far has faced only one technical hurdle to the Medicare attestation process. Even though the EDIS is interfaced with NorthCrest's inpatient EHR, it was not capturing certain information on hospitalized patients that Medicare requires for meaningful use. Specifically, when a hospitalized patient is discharged to home and provided a medication, the information was not being recorded within the ED system. To resolve the problem, Allscripts worked with NorthCrest to create an electronic form enabling end-users to document whenever a patient who was admitted to the hospital from the ED was discharged to home. The documentation process was conducted by a nurse already tasked with reviewing discharges, so it required a minimal amount of new work.

Davis says the biggest difficulty with Medicare attestation has been “understanding all the rules” in the complex reporting process. “Because the ED system is so robust, we do not have to change processes or add any clinical procedures,” he adds.

Davis challenges other hospital CIOs to begin the meaningful-use journey rather than focusing on how hard it is to get started. “There's been a lot of press coverage of CIOs complaining about how hard this process is,” he says.  “Frankly, I think we need to work together, share knowledge about our successes and failures, and figure out how to meet this challenge regardless of the hurdles; it's about maintaining our focus on improving patient care and supporting that improvement
via technology.”


Robert Deberry is director of community development at NorthCrest Medical Center.
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