The hospital would like to participate in the meaningful use EHR incentive program-which Johnston figures represents about $2.5 million in extra funding. But that's assuming the EHR system he is just beginning to install fires on all cylinders in a timely manner, a scenario the CIO does not take for granted. "We're not eligible for meaningful use yet," he says. "But we hope to be there in early 2012 for Stage 1."
Meaningful use is not the only critical deadline the CIO faces. On Jan. 1, 2012, his hospital will-by federal mandate under the HIPAA law-be required to process claims and related transactions in the new 5010 format. Aside from requiring upgrades to San Joaquin's billing and financial management systems, 5010 sets the stage for an even bigger challenge awaiting Johnston, namely conversion to ICD-10, a massively expanded nomenclature of clinical and procedural terms that will replace ICD-9 when it comes online in October 2013.
In the short term, it's a simple equation: no EHR equals no bonus payment, and no 5010 equals no payment whatsoever, at least in theory. "For smaller shops like ours in the early stages of computerized physician order entry and an EHR, the government is forcing us to choose between maximum reimbursement under meaningful use or not getting paid in 2012," he says. "We have to be ready for 5010 in January 2012. It is placing a significant strain on what was already a strenuous exercise. I'm not sure we can't do both, but we're still looking at what 5010 means."
Johnston might well serve as the poster child of a major industry dilemma, one being confronted by hospitals large and small: how to juggle the competing and overlapping deadlines and demands of three government mandates. In context with one another, 5010, MU and ICD-10 symbolize efforts best described as big, bigger and biggest-at least from the I.T. perspective. The 5010 format represents a series of seemingly small yet important changes and upgrades in the way information is passed back forth between providers, clearinghouses and payers (see box, page 29). The rule also codifies a set of standards for electronic prescriptions and other pharmacy transactions (Version D.0 of the National Council for Prescription Drug Programs).
Most experts agree that 5010 will require a system upgrade (or at least a clearinghouse able to convert files from 5010's predecessor, 4010). Yet the good news is that once the 5010 transition is complete, the likely impact on provider workflow will be minimal-perhaps just a handful of new data fields to process-compared with the monumental changes wrought by meaningful use and ICD-10.
Testing, testing
Reaping the benefits of 5010, however, will require thorough preparation on the part of an industry tremendously distracted by meaningful use. And while the transition from 4010 to 5010 itself pales in comparison with the transition from ICD-9 to ICD-10, putting the new claims transaction standard in place will require a round of testing in a government-mandated timeframe that, to many, appears increasingly like wishful thinking. Unlike MU with its staggered deadlines (and even optional participation), 5010 will occur in an industry-wide big bang affecting all claims trading partners.
"The whole industry is behind the government timeline" on 5010, says Dave Biel, principal in the health plan technology practice of Deloitte. Those who have already made progress on their 5010 conversions have learned the transition calls for a detailed examination of vendor readiness and the subsequent establishment of intricate testing timetables to accommodate the often convoluted food chain of the health care claim.
Beyond that, the fast-approaching 5010 enactment date has left many in the industry fretting about inadequate testing and ultimate compliance.
"The challenging view is that the conversion for providers, payers and clearinghouses is all due on the same day," says Jim Riley, president of Capario, a Santa Ana, Calif.-based clearinghouse. Riley decries the absence of the staggered go-live dates that many in the industry pressed for, but did not get, from the federal government. "There is a chance for a huge problem."
Capario processes some 200 million claims annually on behalf of some 8,000 provider organizations, routing them to more than 1,800 payers. According to Riley, fewer than 5 percent of the payers were ready to begin testing for acceptance of 5010 files at the beginning of the year. "If payers don't test until the end of the year, it becomes a scenario where providers will run out of time," he says. "And we sit in the middle of it. Providers have their head in the sand about this issue. Many don't even know what 5010 is. There is a potential train wreck."
Capario is prepared to convert 4010 files to the 5010 format, says Riley. But providers still need to get in touch with their practice management system vendors to help facilitate the transition. "Customers may need to change some of their 4010 data elements when they submit," Riley adds. "They need to do a gap analysis."
The urgency of the 5010 planning process has not yet sunk in industry-wide, according to a poll conducted by HIMSS (see sidebar, page 30). Conducted in mid-2010, about six months before the Jan. 2011 date when trading partners were to begin testing 5010 transactions (as called for, but not mandated, on the government timeline), the poll revealed that only 38 percent of provider respondents have a 5010 conversion project underway-with 35 percent saying they had yet to begin project planning. Most respondents had decided on an approach to meeting 5010 compliance, with 74 percent planning to upgrade current systems. But only 15 percent had started contacting their vendors.
With large numbers of providers apparently waiting until year's end to even begin testing, the industry faces a precarious crunch period, says Joe Miller, director of e-business at AmeriHealth Mercy. The Philadelphia-based payer runs six Medicaid managed care plans in five states, serving some 1.3 million members and processing about 25 million annual claims and related transactions. The payer completed its internal systems upgrade and testing last year for 5010, says Miller.
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