How the 2014 Meaningful Use Final Rule is Playing Out in the Field

Tom Lee, Founder and CEO, SA Ignite
Tom Lee

Guest post by Tom S. Lee, Ph.D., CEO & Founder, SA Ignite.

If the few years since the onset of meaningful use haven’t been proof enough, the speed and unpredictability of regulatory change in the last five months has cemented our field’s status as truly not-for-the-feint-of-heart.

Yesteryear’s glacial rate of change in healthcare IT regulation is nowhere to be seen. May 2014 brought both a CMS reset of the ICD-10 transition deadline to October 1, 2015, and a proposed meaningful use rule to enable the use of 2011 edition certified EHR technology (CEHRT) to meet compliance in 2014. The summer then ended with the August 29th finalization of the 2014 meaningful use final rule, the ensuing disappointment that the mandated start of Stage 2 was not delayed and then the swift Congressional response in the form of the September 15th proposed Flex-IT Act to introduce quarterly meaningful use reporting for 2015; enough to spin heads more than once around.

What’s happened in the field since the publication of the final rule among provider organizations bring the phrase “threading the needle” to mind. To further illustrate, we have culled some sample issues from our client base of more than 8,000 providers, across more than 15 EHR brands, and representing numerous combinations of meaningful use stage, payment year and program. These issues, none of which yet have universal and clean solutions, span three areas for provider organizations as seen in the field: 1) properly adhering to the requirements of the final rule, 2) working within the constraints of what EHR vendors can deliver per the final rule’s timeline, and 3) redirecting or pausing organizational momentum for change on short notice.

Regarding the first consideration, note that the final rule requires that an organization attest that it is “not able to fully implement” 2014 Edition technology because of “delays in 2014 Edition CEHRT availability.” Although the rule outlines what does not meet this eligibility test, provider organizations have a persistent question about what documentation and conditions are sufficient to satisfy the test.

The concern is warranted because the meaningful use final rule states that eligibility is subject to audit. For instance, what’s the eligibility documentation audit trail needed for an organization using a particular brand of EHR with well publicized delivery delays that have equally impacted all its clients? Will just recording the installed product name and version be sufficient? Compare that to the additional documentation potentially needed by an organization on an EHR that has been implemented on time for other organizations this year. What’s needed to show that enough factors were out of the organization’s control to move it into the range of eligibility for the final rule? In particular, if an organization has been on 2014 edition technology since, say, sometime in the first half of the year, and was pre-final rule accountable to meeting Stage 2 then the organization may fear greater scrutiny by CMS or the auditors should it decide to attest to Stage 1, claiming eligibility for the final rule.

We see organizations documenting emails, copies of support tickets and frequencies of hot fix releases to support their assertion that their system is not “fully implemented” even after an official go-live early in the second quarter. In particular, organizations assert that it is difficult, if not impossible, for them to fully complete training on new workflows with these constant re-releases of new functionality or fixes of unstable areas of the system. This issue comes with some empathy for the EHR vendors as there is recognition that it was the Stage 2 certification push that’s the root cause.

Second, EHR vendors have varied widely in their ability to quickly adjust their product rollouts and roadmaps to enable clients to take advantage of the options presented by the final rule. For instance, although the final rule allows the use of 2011 edition technology, some vendors are not able to provide historical reports from the 2011 system after the upgrade to the 2014 edition has been completed. In some of these cases, clients are waiting for reporting to be available, rendering them blind to provider performance.

The number of situations is rising in which provider organizations are tempted to make special requests of their vendors just to leverage the final rule. Vendors must then handle such requests at the latest by the end of 2014, which then potentially further delays their ability to broadly roll out 2014 edition CEHRT in time for the mandated start of Stage 2 in 2015; assuming the Flex-IT Act does not get passed.

A price of greater 2014 meaningful use flexibility appears to be a deepening of the EHR delivery hole which many vendors are still trying to dig their way out of.

Last and perhaps most important, many provider organizations invested time and resources early in the year to build organizational momentum toward achieving Stage 2, assuming that the EHR vendors would deliver by certain dates. As vendor delays piled up, culminating with the release of the May proposed meaningful use rule allowing the use of 2011 edition technology, these provider organizations had a critical decision to make: Continue barreling towards Stage 2 or slow down to stay on Stage 1.

Opting for the latter required careful communication to providers that the previous sense of urgency around achieving Stage 2 should not now be ignored and was not a case of “cry wolf,” but is expected to be revived in the near future. Then, the approval of the final rule in August meant that the “near future” was suddenly and, for many, surprisingly October 1 for hospitals and January 1 for eligible providers to begin Stage 2 for FY/CY 2015. In other words, providers and staff experienced a screeching halt, immediately followed by a pedal-to-the-metal acceleration back towards Stage 2, leaving many to wonder what and who to believe. And, this is apart from the possibility that the Flex-IT Act is passed, causing the brakes to be slammed down yet again.

Even organizations highly-skilled and experienced in change management are struggling to navigate, communicate and manage these rapid oscillations. We have seen organizations that survived early adoption of a 2014 CEHRT holding providers to Stage 2 standards while separately tracking those providers’ Stage 1 performance strictly for 2014 attestation purposes. Such duplicate work is not uncommon during this transitional period.

One over-arching constant we’ve seen in the provider community throughout these tumultuous changes in the meaningful use program is the critical benefit of sharing experiences among peers.

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