HIE-heavy Stage 2 not in a hurry

Stage 2 of the federal Electronic Health Records Incentive Program is underway for providers who first reached Stage 1 in 2011. Although there will not be any official statistics available for several months, anecdotal evidence suggests that this new phase is off to a slow start.

Healthcare providers, EHR vendors and other health IT industry insiders have identified several pain points that seem to be hindering the migration from Stage 1 to Stage 2. Notably, providers have to juggle multiple healthcare reform efforts simultaneously and are struggling with Stage 2 requirements to engage and educate patients.
Vendors have tight timelines to bring their EHRs up to Stage 2 standards, and are unclear about new testing for usability. Any delay on the vendor side naturally makes achieving meaningful use more difficult for their customers.
And, of course, entities in all sectors of healthcare continue to lag when it comes to interoperability of electronic health information.
All these problems may call into question the viability of meaningful use, but, despite the headaches, there seems to be widespread — though certainly not universal — agreement that this $27 billion, multiyear program is moving healthcare in the right direction.
"I see this as a stepping stone to expanding your abilities down the pike," perhaps moving some patient encounters to telemedicine in the future, says Sam DiCapua, DO, one of three physicians at Wells Family Practice in Wells, Maine.
"I really look at this as an opportunity for physicians like me to get off the hamster wheel," adds DiCapua, who has grown tired of having to cram as many short, often meaningless patient visits into his day in order to pay the bills. "If the doctor is disgruntled and unhappy, it rubs off on their staff and their patients," he adds.
"We are in a major transition in healthcare," DiCapua says. But he believes the payoff will be worth it.
"Before, it was like flying an airplane without instruments," says DiCapua, who reached Stage 1 in 2011 and expects to attest to Stage 2 meaningful use this year.
Prior to having an EHR, he would tell a patient to get a mammogram, the patient would agree, but then there was no way of knowing if she ever followed up, so the order loop was never closed. Now, DiCapua, or one of his colleagues puts in the order for a mammogram or other test and sends the referral electronically to an imaging center or specialist. If no result comes back, he knows the loop has not been closed and he can act accordingly.
"We want (meaningful use) to succeed," agrees Russell Branzell, president and CEO of the College of Healthcare Information Management Executives.
For that to happen, however, various players in the healthcare industry will have to overcome some high obstacles and likely endure significant pain in the short term. Already, problems have cropped up.
Branzell reports that CHIME surveyed CIOs from organizations that were early adopters of health IT. Of the 33 who said they would attest to achieving Stage 2 in January, none did. Close to half of these said they would be delayed significantly, perhaps six months or more.
"It takes a while to get the software in. It takes a while to mature it. It takes a while to get the data flowing," Branzell says.
And there are so many issues to address along the way.
Robert Tennant, Washington-based senior policy advisor for the Medical Group Management Association, attributes some of the meaningful use-related stress to the overlap with ICD-10. The last day for hospitals to attest to Stage 2 meaningful use for 2014 is Sept. 30, one day before the new coding system must be in place for all Medicare providers. Individual eligible providers must begin their 90-day attestation period no later than Oct. 1, or they not only lose out on incentive payments for the year, they will face Medicare penalties going forward.
"There's a lot on the plates of vendors and providers this year," Tennant says. In addition to ICD-10, hospitals, physician practices and vendors alike are struggling with healthcare reform initiatives that include health information exchange, accountable care and determining the eligibility of patients who are newly insured through Affordable Care Act insurance exchanges and Medicaid expansion.
Complicating matters, Branzell says that the Centers for Medicare and Medicaid Services' meaningful use attestation website has not been functioning properly for several months.
With this and with the shaky launch of the HealthCare.gov health insurance exchange, Branzell is losing confidence in the Department of Health and Human Services, wondering if Medicare will be ready to accept claims in ICD-10 by Oct. 1, the date providers must start using the new coding system. "Once you flip the switch, you can't go back," Branzell says.
For providers to achieve meaningful use, they must use an EHR certified by an ONC-authorized testing body. Vendors have had to scramble to bring their products up to speed for Stage 2 ever since the federal government finalized the current round of meaningful use standards in September 2012.
Only after the products they use gain certification to the new 2014 standards can healthcare providers begin measuring and attesting to Stage 2 meaningful use. But hundreds or even thousands of complete EHRs and EHR modules certified for Stage 1 have not been upgraded to Stage 2 standards (see sidebar), potentially leaving customers in the uncomfortable position of having to change vendors in midstream.
CMS does exempt providers from certain provisions based on "hardship." There have been some unconfirmed rumors that CMS is considering exempting customers of vendors that do not get certified for Stage 2.
One new twist to certification is that the designated testing bodies now must evaluate EHRs for usability, but they do so based on some rather vague instructions.
Usability certification for meaningful use really isn't a test the way the rest of the certification process is, according to Bennett Lauber, chief experience officer of The Usability People, a Fairfax, Va.-based firm that consults on improving user experiences with technology and offers usability testing services.
"(Testers) go out and observe users, and report back to the certifiers," Lauber reports. There seem to be different sets of evaluation criteria because ONC has not really defined usability yet, he adds.
"There are questions and confusion among vendors about what the usability test is," Lauber says. "(Vendors) think they can just do it themselves," and some want to in order to save money.
"There's some education that needs to be done for the vendors," he says. Vendors: "They're just as confused, too."
Lauber suspects that the usability part could lead to a lot of vendors dropping out of meaningful use, creating problems for customers who might get left in the lurch.
Worse, according to Alexander Romanychev, CEO of WCH Service Bureau, Brooklyn, N.Y., a medical billing company that recently launched an ambulatory EHR with the help of The Usability People, some physicians would rather take the Medicare penalties starting in 2015 than wrestle with a difficult-to-use EHR. Romanychev says some vendors have built user bases not by delivering good products, but by undertaking successful marketing efforts, a point that is hard to argue.
"The major issue is the features of the software," Romanychev says. He says physicians often choose EHRs based on price, which is why some free products have become popular, even if the EHRs are not flexible enough to meet their particular needs. "They take it, then they complain," Romanychev says.
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