Stumbling out the starting gate

Stage 2 meaningful use proved problematic in 2014
By Mike Miliard
02:28 PM
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The mood was hopeful as 2014 dawned.

"This is the year," said Robert Tagalicod, director of the Office of E-Health Standards and Services at the Centers for Medicare & Medicaid Services, speaking in February at HIMSS14 in Orlando as the industry prepared for the kick-off of Stage 2 meaningful use attestations.

But as the months wore on, some of that initial enthusiasm began to wane. And, before long, some industry groups were wondering whether unreasonable expectations were threatening the very future of meaningful use.

In March, we reported how, even though official attestation stats wouldn't be available for months, anecdotal evidence was surfacing to suggest that Stage 2 was off to a slow start.

Hospitals, practices and technology developers were having trouble juggling the competing priorities of MU, ICD-10 and mandates related to health reform and the Affordable Care Act.

"There's a lot on the plates of vendors and providers this year," said Robert Tennant, senior policy advisor for the Medical Group Management Association.
By the summer, numbers were starting to roll in, and they weren't encouraging.


CMS and ONC revealed statistics July 8 showing that just 1 percent of eligible providers and 3 percent of eligible hospitals had attested to Stage 2.

But Elisabeth Myers, policy and outreach lead at CMS' Office of e-Health Standards and Services emphasized that this was early data, and it was "dangerous to apply interpretations" to such a relatively small sampling.

Still, one thing was beyond dispute: Stage 2 was far and away more difficult to achieve than Stage 1.

The most difficult measures, of course, were – and continue to be – those that depend on cooperation or connection with outside parties: whether it's the 5 percent threshold for patients to view, download or transmit their health data, or the 10 percent threshold for electronic transmission of care summaries.

Early in the summer, we showed how New York Hospital Queens, by making a "full-court press" on patient access, is well positioned to achieve the former measure. But the latter requirement is still posing a formidable challenge, said Kenneth Ong, MD, the hospital's chief medical informatics officer.

"The summary of care measure? It's been a challenge for us, as well as others," said Ong. "One problem is actually getting the technology to work."

Direct messaging has been a particular problem, he said. "We've been working on that with our vendor now – who I will not name – for more than two months," said Ong when we spoke in late June. "Despite adding a number of hotfixes, they still have not been able to get it to work."

Stage 2 was daunting, on every level: people, process and technology.

"I didn't really know what to expect when I came into it," said Rick Frederick, Cottage Hospital's chief information officer of rural Cottage Hospital, a critical access facility in Woodsville, N.H. "I wasn't expecting the challenges that we did in fact encounter."

Stage 1 attestation required "less than one-tenth" of the data Stage 2 did, he said, posing big challenges for his staff (Cottage's IT team comprises just six FTEs) and his infrastructure.

"This additional logging/processing dictated most of our need for more capable hardware," said Frederick. "For Stage 2 it was a complete forklift upgrade of our core servers that handle the system."

'Flexibility,' but not the right kind

On Aug. 29, the Department of Health and Human Services published a final rule for Stage 2 meaningful use that touted 'flexibility' for hospitals and physicians.

It offered more give-and-take on meaningful use objectives such as drug interaction and drug allergy checks, clinical summaries, e-prescribing, public health reporting and quality measures. “We listened to stakeholder feedback," Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner said in a news release. "We were excited to see that there is overwhelming support for this change."

But stakeholders were unhappy with the rule. Most notably, they were aghast that CMS was holding firm on a full-year reporting period, rather than the 90-day window that had been repeatedly requested by beleaguered providers.

"CHIME is deeply disappointed in the decision made by CMS and ONC to require 365 days of EHR reporting in 2015," said CHIME CEO Russell Branzell in a press statement. "This single provision has severely muted the positive impacts of this final rule. Further, it has all but ensured that industry struggles will continue well beyond 2014."

A couple weeks later, in a pointed letter sent to HHS Secretary Sylvia Mathews Burwell, CHIME and several other industry groups – including HIMSS, MGMA, AHA, AMA and others – complained of "immediate concerns" about their members' ability to continue participating in meaningful use.

A "shortened, 90-day EHR reporting period in 2015, would give time for providers to continue their transition without having to drop out of the program," they write.

The numbers speak for themselves, the groups argued: as of mid-September, just 143 hospitals and 3,152 providers had been able to meet Stage 2 with 2014 Edition EHRs.

"This represents less than 4 percent of the hospitals required to be Stage 2-ready within the next 15 days," the groups wrote. "And while eligible professionals have more time, they are in comparatively worse shape, with only 1.3 percent of their cohort having met the Stage 2 bar thus far."

As if on cue, the next day a new bi-partisan bill was filed in the House of Representatives by Republican North Carolina Congresswoman Renee Ellmers. H.R.  5481, The Flexibility in Health IT Reporting (Flex-IT) Act of 2014 was crafted to offer providers the kind of flexibility they'd been clamoring for, remedying HHS' "short-sighted final rule" requiring 365 days of EHR reporting in 2015.

"The meaningful use program has many important provisions that seek to usher our health care providers into the digital age," said Ellmers in a press statement. "But instead of working with doctors and hospitals, HHS is imposing rigid mandates that will cause unbearable financial burdens on the men and women who provide care to millions of Americans. Dealing with these inflexible mandates is causing doctors, nurses, and their staff to focus more on avoiding financial penalties and less on their patients."

By giving providers the option to choose any three-month quarter for the EHR reporting period in 2015 to qualify for MU, "hundreds of thousands of providers" would have a better shot of meeting Stage 2 requirements safely and effectively.

As of this writing, CMS has not relented on the shortened reporting window, but the Flex-IT Act had been referred to the House Subcommittee on Health and was said to be gaining steam.

Meanwhile, most hospitals and practices – the ones that weren't thinking seriously about forswearing the program, at least – were trying to slog through Stage 2 as best they could.