Endless Mountain Health System

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By CereCore | Jul 20, 2020

2 minute read MEDITECH| Case Study

Addressing Compliance And Quality Measures As A Smaller Health System

The Client

  • Endless Mountain Health Systems

The Facility

  • Critical Access Hospital
  • 25 Licensed Beds


  • Improved QA scores
  • Continuous readiness for new regulatory requirements
  • Strengthened meaningful use measures program after loss of internal resources

Endless Mountain Health Systems (EMHS) is a not-for-profit health system in Montrose, Pennsylvania. The hospital utilizes MEDITECH EHR and has a small internal team supporting their technologies. Here, EMHS’s Administrative Director of Information Technology, Bradley Adleman, discusses their approach to regulatory compliance and quality measures – including the hidden value in the effort.


What has been your approach to addressing regulatory changes and requirements for your organization?
We are a smaller health system, and while we have a strong commitment to quality, we don’t have a Quality Assurance department at the scale of larger organizations. We experienced losses in the internal staff that was handling our medical records support and that included building queries for Meaningful Use measures. We needed someone who could take a look at our current situation and figure out what we needed to get done to meet the measures – especially ones that we weren’t really familiar with.

We had been working with CereCore® for day-to-day support and other MEDITECH projects on a time and materials basis and knew their work was done right, on time, and on budget. I can call them in the middle of the night with my hair on fire and always get an answer. So we approached them regarding their capabilities around interoperability and regulatory compliance.

We found in CereCore a team of highly specialized regulatory and technical experts who could properly assess our QA and provide services around the site setup, decision workflows, technical setup, and ongoing support. They operate as an extension of our organization. It’s nice to have a resource that knows their stuff. I doubt we could have accomplished the same results without them.

Where does your organization stand with regulatory compliance and are you ready for the 2021 Appropriate Use Criteria (AUC) deadline?
The work we’ve done with CereCore includes a quarterly report scoring our quality measures. Our last report demonstrated a 28 point bump and our QA measures look really great. In regards to the AUC program date, we are already submitting appropriate use criteria to the Centers of Medicare Services (CMS) and have a baseline of results that demonstrate readiness.

The effort and cost to achieve compliance can be more challenging to a smaller health system. What was the value of approaching compliance the way your organization did?
Not everyone understands the amount of effort, cost, and complexity to achieve good quality measures scores. And for some smaller health systems, the all-in costs of compliance can rival the cost in penalties. Yet, while there are obvious financial ramifications to non-compliance, the effort has had tremendous value for us. Our ability to impact quality from the reports, dashboards, and intelligence we have from our interoperability efforts have helped us deliver better care and make it easier for providers and nursing departments.

How do you plan to deal with regulatory changes moving forward?
Internally, we plan to further consolidate quality efforts and drive improvements to the various units in our organization. We will also continue to rely on CereCore to support any changes that may occur. We simply can’t replicate the expertise we have with CereCore. No matter what CMS comes up with, they see it coming and know how to deal with it.

If you could offer one piece of advice to a peer dealing with regulatory changes in their health system, what would that be?
We often look at compliance almost as a burden. It’s something you have to do. It is very important to make sure credit is given to the good work you do whether through quality measures, surveys, etc. It’s tireless, complex work but it delivers tremendous value and peace of mind to the entire organization.

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