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Are Changes to Meaningful Use Certification Coming?

Posted on February 10, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I’d been meaning to write about the now infamous letter from the AMA and 20 other associations and organizations to Karen DeSalvo (ONC Chair and Assistant HHS Secretary). I’ve put a list of the organizations and associations that co-signed the letter at the bottom of this post. It’s quite the list.

In the letter they make these recommended changes to the EHR certification program:

1. Decouple EHR certification from the Meaningful Use program;
2. Re-consider alternative software testing methods;
3. Establish greater transparency and uniformity on UCD testing and process results;
4. Incorporate exception handling into EHR certification;
5. Develop C-CDA guidance and tests to support exchange;
6. Seek further stakeholder feedback; and
7. Increase education on EHR implementation.

Unfortunately, I don’t think that many of these suggestions can be done by Karen and ONC. For example, I believe it will take an act of Congress in order to decouple EHR certification from the meaningful use program. I don’t think ONC has the authority to just change that since they’re bound by legislation.

What I do think they could do is dramatically simplify the EHR certification requirements. Some might try to spin it as making the EHR certification irrelevant, but it would actually make the EHR certification more relevant. If it was focused on just a few important things that actually tested the EHR properly for those things, then people would be much more interested in the EHR certification and it’s success. As it is now, most people just see EHR certification as a way to get EHR incentive money.

I’ll be interested to see if we see any changes in EHR certification. Unfortunately, the government rarely does things to decrease regulation. In some ways, if ONC decreases what EHR certification means, then they’re putting their colleagues out of a job. My only glimmer of hope is that meaningful use stage 3 will become much more simpler and because of that, EHR certification that matches MU stage 3 will be simpler as well. Although, I’m not holding my breathe.

What do you think will happen to EHR certification going forward?

Organizations and Associations that Signed the Letter:
American Medical Association
AMDA – The Society for Post-Acute and Long-Term Care Medicine
American Academy of Allergy, Asthma and Immunology
American Academy of Dermatology Association
American Academy of Facial Plastic
American Academy of Family Physicians
American Academy of Home Care Medicine
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngology—Head and Neck Surgery
American Academy of Physical Medicine and Rehabilitation
American Association of Clinical Endocrinologists
American Association of Neurological Surgeons
American Association of Orthopaedic Surgeons
American College of Allergy, Asthma and Immunology
American College of Emergency Physicians
American College of Osteopathic Surgeons
American College of Physicians
American College of Surgeons
American Congress of Obstetricians and Gynecologists
American Osteopathic Association
American Society for Radiology and Oncology
American Society of Anesthesiologists
American Society of Cataract and Refractive Surgery and Reconstructive Surgery
American Society of Clinical Oncology
American Society of Nephrology
College of Healthcare Information Management Executives
Congress of Neurological Surgeons
Heart Rhythm Society
Joint Council on Allergy, Asthma and Immunology
Medical Group Management Association
National Association of Spine Specialists
Renal Physicians Association
Society for Cardiovascular Angiography and Interventions
Society for Vascular Surgery

Congress Asks ONC to Decertify EHRs That Proactively Block Information Sharing

Posted on December 22, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

A big thanks to A. Akhter, MD for pointing out the 2014 Omnibus Appropriations bill (word is in Washington they’re calling it the CRomnibus bill) which asks ONC to address the interoperability challenges. HIMSS highlighted the 2 sections which apply to ONC and healthcare interoperability:

Office of the National Coordinator for Information Technology – Information Blocking.

The Office of the National Coordinator for Information Technology (ONC) is urged to use its certification program judiciously in order to ensure certified electronic health record technology provides value to eligible hospitals, eligible providers and taxpayers. ONC should use its authority to certify only those products that clearly meet current meaningful use program standards and that do not block health information exchange. ONC should take steps to decertify products that proactively block the sharing of information because those practices frustrate congressional intent, devalue taxpayer investments in CEHRT, and make CEHRT less valuable and more burdensome for eligible hospitals and eligible providers to use. The Committee requests a detailed report from ONC no later than 90 days after enactment of this act regarding the extent of the information blocking problem, including an estimate of the number of vendors or eligible hospitals or providers who block information. This detailed report should also include a comprehensive strategy on how to address the information blocking issue.”

Office of the National Coordinator for Information Technology – Interoperability.

The agreement directs the Health IT Policy Committee to submit a report to the House and Senate Committees on Appropriations and the appropriate authorizing committees no later than 12 months after enactment of this act regarding the challenges and barriers to interoperability. The report should cover the technical, operational and financial barriers to interoperability, the role of certification in advancing or hindering interoperability across various providers, as well as any other barriers identified by the Policy Committee.”

Everyone is talking about the first section which talks about taking “steps to decertify products that proactively block the sharing of information.” This could be a really big deal. Unfortunately, I don’t see how this will have any impact.

First, it would be really hard to prove that an EHR vendor is proactively blocking information sharing as required by EHR certification. I believe it will be pretty easy for an EHR vendor to show that they meet the EHR certification criteria and can exchange information using those standards. From what I understand, the bigger problem is that you can pass EHR certification using various flavors of the standard.

It seems to me that Congress should have really focused on why the meaningful use requirements were so open ended as to not actually get us to a proper standard for interoperability. They kind of get to this with their comment “certify only those products that clearly meet current meaningful use program standards.” However, if the MU standards aren’t good, then it doesn’t do any good to make sure that EHR vendors are meeting the MU program standard.

Of course, I imagine ONC wasn’t ready to admit that the MU standard wasn’t sufficiently defined for quality interoperability. Hopefully this is what will be discovered in the second piece of direction ONC received.

I could be wrong, but I don’t think the problem is EHR vendors not meeting the MU certification criteria for interoperability. Instead, I think the problem is that the MU certification criteria isn’t good enough to achieve simple interoperability between EHR systems.

If you think otherwise, I’d love to be proven wrong. Does this really give ONC some power to go after bad actors?

As an extension to this discussion, Carl Bergman has a great post on EMR and EHR which talks about what’s been removed from this bill. It seems that the Unique Patient Identifier gag rule has been removed.

RIP CCHIT

Posted on October 29, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

CCHIT announced that it was ending 10 years of service.

Today, the Certification Commission for Health Information Technology (CCHIT) announced that it is winding down all operations beginning immediately. All customers and business colleagues have been notified, CCHIT staff is assisting in transitions, and all work will be ended by November 14, 2014.

Alisa Ray made these comments in the announcement:

“We are concluding our operations with pride in what has been accomplished”, said Alisa Ray, CCHIT executive director. “For the past decade CCHIT has been the leader in certification services, supported by our loyal volunteers, the contribution of our boards of trustees and commissioners, and our dedicated staff. We have worked effectively in the private and public sectors to advance our mission of accelerating the adoption of robust, interoperable health information technology. We have served hundreds of health IT developers and provided valuable education to our healthcare provider stakeholders.”

“Though CCHIT attained self-sustainability as a private independent certification body and continued to thrive as an authorized ONC testing and certification body, the slowing of the pace of ONC 2014 Edition certification and the unreliable timing of future federal health IT program requirements made program and business planning for new services uncertain. CCHIT’s trustees decided that, in the current environment, operations should be carefully brought to a close”, said Ray.

The announcement also said that CCHIT would be donating its remaining assets to the HIMSS Foundation. Makes sense since HIMSS kind of gave them a partial home the past few months as they tried to save the jobs of the many who worked at CCHIT. Credit should go to Alisa Ray for all she did to try and give those who worked at CCHIT a soft landing.

Long, long time readers of this blog will remember my long blog posts talking about CCHIT and the lack of value that they provided the EHR industry. I believed then and even now that EHR certification was more of a tax on the industry than it was something that provided value to the market. They told me it provided some assurance to the purchaser of the EHR, but I never saw such assurances.

Once EHR certification was made part of meaningful use and the HITECH act, it basically made CCHIT irrelevant. Although, I still think that EHR certification in its current state doesn’t provide value to organizations and I’d love to see it go away. Sadly, there’s some legislation which is pushing the opposite direction.

While I disagreed with CCHIT’s approach to EHR certification and the value they provided, I do think there were good people who worked there that had good intentions even if we disagreed on the approach. I hope they all land somewhere great.

EHR Certification Flexibility Final Rule Commentary and Analysis

Posted on September 3, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

The news came out late on Friday that the EHR Certification flexibility was published as a final rule. I covered my initial take on the EHR Certification Flexibility on Hospital EMR and EHR. I’ve now had a chance to dig through the delicious 90 pages of government rule making and comments that make up the final rule. For those following along at home, you can skip to page 10 of the document to start the fun read. Although, I’ll also direct you to specific sections that might be of interest to you below.

In this post, I’ll just cover the EHR certification flexibility. You can see the meaningful use extension and delay timelines here. Here’s the important chart when talking about the EHR Certification flexibility (CMS Calls it CEHRT):
2014 EHR Certification Flexibility - CEHRT

The EHR Certification flexibility has a number of major talking points:

  • What Does “unable to fully implement” and “2014 Edition CEHRT availability delays” mean?
  • Fairness of EHR Certification Flexibility
  • 90 Day Reporting Period in 2015 Instead of 365 Days
  • Future Audits

What Does “unable to fully implement” and “2014 Edition CEHRT availability delays” mean?
On page 62 of the rule is the best description of the rule’s intent. It says that if you want to take advantage of this EHR flexibility, then they (Eligible providers or hospitals) “must attest that they are unable to fully implement 2014 Edition CEHRT because of issues related to 2014 Edition CEHRT availability delays when they attest to the meaningful use objectives and measures.” This basically covers the asterisk in the chart above.

This piece of the rule was so unclear that CMS in the final rule used 12 pages (pg. 36-48) to describe when this rule would apply and when it would not apply. CMS tried to make this apply as broadly as possible, but I think they also wanted to encourage as many organizations as possible to not use the exception.

My short summary of these 12 pages is: If you have the 2014 Certified EHR software and can attest to meaningful use stage 2, then you better go ahead and do it. Trying to find a loophole that allows you to avoid meaningful use stage 2 and just do MU stage 1 puts you at risk during a future meaningful use audit.

Of course, if you’re EHR vendor hasn’t provided you the proper software/updates/training, etc that you require to attest to meaningful use stage 2, then this rule will apply. CMS’ intent seems pretty clear. If you can attest to meaningful use stage 2, then you should. However, if your EHR vendor prevents you from being able to attest, then they don’t want to hold the providers accountable for the EHR vendors failure. Although, CMS notes multiple times in the final rule that they don’t want to point blame at the EHR vendors since it could have been other outside issues (ie. final rule was late, ONC-ACB’s were backlogged, etc) that caused the EHR vendors to not be ready.

I wonder if one of the unintended side effects of this rule will be EHR vendors taking their sweet time releasing and rolling out their 2014 Certified EHR product and updates. It’s too late for this in the hospital setting since hospitals have to do a full year of MU 2 on a 2014 Certified EHR starting October 1, 2014. However, the same might not be true on the ambulatory side where they have until the end of the year to start on meaningful use stage 2.

I’ll be interested to see how many organizations are able to take advantage of this delay. Had this rule been finalized in early 2014, it would be a very different story. However, at this late date, I’m not sure that many providers or hospitals will be able to change course.

I mostly feel bad for those organizations that rushed their EHR implementations onto barely-beta-tested 2014 Certified EHR software and will now have no choice but to go forward with meaningful use stage 2. This change in rule makes many of these organizations wish they’d slowed their implementation to make sure they’d done it right and they’d have also only been required to do MU stage 1.

Fairness of EHR Certification Flexibility
The last paragraph above highlights part of the reason why many providers feel that this EHR certification flexibility is unfair. While it’s not a direct penalty on organizations that were on top of things, the change rewards those organizations that didn’t take the risks, push their EHR vendors, and push their implementation timelines to meet the MU stage 2 requirements. The reward an organization gets for going after MU stage 2 is that they have to do a lot more work (Yes, MU2 is A LOT more work) while their procrastinating competitors get to do the much simpler MU1.

This was such an important complaint that CMS addressed these comments in two different places in the final rule (pg. 21-22 and pg. 48-50). CMS tries to argue that in their research they didn’t see providers that were deliberately trying to delay MU stage 2, but found that providers wanted to do MU stage 2, but their EHR vendors weren’t ready. I’d suggest that CMS may want to dig a little deeper.

However, let’s set providers aside for now and assume that they all want to do MU stage 2, but their EHR vendors just aren’t ready for it. This EHR certification flexibility still lets EHR vendors who procrastinated their 2014 EHR certification off the hook. In fact, it rewards them and their users for not performing well. Once again, CMS doesn’t want to point the finger at EHR vendors, but will blame themselves for not finalizing the rule fast enough and ONC-ACB’s for having a backlog. However, if you’re an EHR vendor who’s been 2014 Certified for a while now, no doubt this rule makes you angry since it rewards your competitors in a big way (intended or otherwise).

Certainly there are a lot of reasons why an EHR vendor isn’t yet ready to be 2014 Certified. However, most of them have little to do with the rule making process and the EHR certification backlog. Some freely admit it, and others hide behind excuses. I think CMS realized this EHR Certification flexibility would benefit these EHR vendors, but they didn’t want to punish the providers who use these EHR software.

I still think the simple solution here was to extend this same flexibility to all providers and all EHR vendors. However, in the final rule CMS argues that doing so would reduced the amount of meaningful use stage 2 data that they’d have available to make the adjustments needed to meaningful use stage 3. I understand how a provider doing MU stage 2 this year might feel like the government’s guinea pig. We need you to do MU stage 2 so we can figure out how to make it right in MU stage 3. CMS also argues that they need more people on meaningful use stage 2 in order to push their agenda and the intent of the HITECH act forward. What doesn’t seem aligned to me is the goals of meaningful use and providers’ goals. I think that’s why we see such a disconnect.

90 Day Reporting Period in 2015 Instead of 365 Days
This seems to be one of the most heated discussion points with the final rule. CHIME President and CEO, Russell P. Branzell, even suggested that “Now, the very future of Meaningful Use is in question.”

CMS’ comments about this (pg. 34-36) basically say that a change to the EHR reporting periods was not part of this proposed rule. Then, they offered this reason for why they’re not considering changes to the reporting periods:

We are not considering changes to the EHR reporting periods for 2015 or subsequent years in this final rule for the same reasons we are not considering changing the edition of CEHRT required for 2015 or subsequent years. Changes to the EHR reporting period would put the forward progress of the program at risk, and cause further delay in implementing effective health IT infrastructure. In addition, further changes to the reporting period would create further misalignment with the CMS quality reporting programs like PQRS and IQR, which would increase the reporting burden on providers and negatively impact quality reporting data integrity.

What this comment doesn’t seem to consider is what will happen if almost no organizations choose to attest to meaningful use because of the 365 day reporting period. Talk about killing the “forward progress” of the program. From a financial perspective, maybe that’s great for the MU program. CMS will pay out less incentive money and they’ll make back a bunch more money in the eventual penalties. However, it seems counter to the goal of increasing participation in the program. Personally, I’m not sure that the end of organization’s participation in meaningful use would be such a bad thing for healthcare. It would lead back to a more rationale EHR marketplace.

Future Audits
On page 55-56, the final rule addresses the concerns over audits. We can be sure that some organizations will be audited on whether they were “unable to fully implement 2014 Edition CEHRT because of issues related to 2014 Edition CEHRT availability delays.” Sadly, the final rule doesn’t give any details on what documentation you should keep to illustrate that you meet these requirements for which you will have to attest. The final rule just says that they’ll provide guidance to the auditors on this final rule and that audit determinations are finalized on a case by case basis that will cover the varied circumstances that will exist.

This wouldn’t give me much comfort if I was going through an audit. Not to mention comfort that the auditors wouldn’t interpret something differently. I’ll defer other audit advice to my auditor friends, since I’m not an audit expert. However, in this case you likely know how far you’re stretching the rule or not. That will likely determine how comfortable you’ll be if an audit comes your way. Now you can see why my advice is still, “If you have the 2014 Certified EHR software and can attest to meaningful use stage 2, then you better go ahead and do it.

Conclusion
I really see the meaningful use program on extremely shaky ground. I don’t think this final rule does much to relieve any of that pressure. In fact, in some ways it will solidify people’s bad feelings towards the program. We’ll see for sure how this plays out once we see the final numbers on how many organizations attest to meaningful use stage 2. I don’t think those numbers are going to be pretty and 2015 could even be worse.

Note: For those following along at home (or work), here’s the final rule that I reference above.

Lack of Rec Support Cause of Meaningful Use Stage 2 Slowdown?

Posted on May 21, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

By now, I imagine that most of you have read about the meaningful use stage 2 delay and EHR certification flexibility. The details and interpretation are still going on, but it’s a big change to the current meaningful use program. Although, the biggest question I hear asked is if the change leaves enough time for organizations to change course. I think the rule has to be open for 60 days of comment before it becomes final. We’ll see if that leaves people enough time.

We’ll see if this change will provide some relief to a meaningful use program that I described as on the ropes. In response to that post, Deborah Sherl, BSN, RN, CHTS, CHPS, made an interesting comment on a possible cause of the meaningful use stage 2

@ John Lynn…. of course I am slightly biased on the topic of the rapid response & deployment of Stage 1 vs Stage 2. A great amount of Stage 1 success was ushered in with the amazing assistance of professional consultants across the country for those EPs & EHs that were willing to use us…. and we were called the Regional Extension Centers Health IT workforce.

Now that the federal grant is done (Feb.2014) Stage 2 implementations are possibly stalled not only by overburdened EMR vendors, but lack of project management forces that were provided by the RECS. Many RECs have built sustainable business models but are no longer “free” services as was perceived while under the HITECH grant.

I find this a very interesting hypothesis. I’m not sure that it accurately reflects why many organizations chose not to attest to MU stage 2, but it certainly didn’t help things. In fact, it adds one more log to the already burning fire. Think about what happens with MU stage 2. We’re going to pay them less incentive money, require them to do substantially more, and oh yeah…those “free” REC support resources are now gone too. Plus, your EHR vendor may or may not be ready either.

I think the changes to the EHR Certification requirements and delay of meaningful use stage 2 are good. Although, I’m hoping this is just the start of HHS blowing up meaningful use and making it dramatically simpler and more meaningful.

Lack of 2014 Certified EHRs

Posted on April 11, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I was asked recently by an EHR vendor about the disconnect between the number of 2011 Certified EHR and the number of 2014 Certified EHR. I haven’t looked through the ONC-CHPL site recently, but you can easily run the number of certified EHR vendors there. Of course, there’s a major difference in the number of 2011 certified EHR versus 2014 certified EHR. However, I don’t think it’s for the reason most people give.

Every EHR vendor that gets 2014 Certified likes to proclaim that they’re one of the few EHR vendors that was “able” to get 2014 Certified. They like to point to the vast number of EHR that haven’t bridged from being 2011 Certified to being 2014 Certified as a sign that their company is special because they were able to complete the “more advanced” certification. While no one would argue that the 2014 Certification takes a lot more work, I think it’s misleading for EHR companies to proclaim themselves victor because they’re “one of the few” EHR vendors to be 2014 Certified.

First of all, there are over 1000 2014 Certified EHR products on ONC-CPHL as of today and hundreds of them (223 to be exact – 29 inpatient and 194 ambulatory) are even certified as complete EHR. Plus, I’ve heard from EHR vendors and certifying bodies that there’s often a delay in ONC putting the certified EHR up on ONC-CPHL. So, how many more are 2014 Certified that aren’t on the list…yet.

Another issue with this number is that there is still time for EHR vendors to finish their 2014 EHR certification. Yes, we’re getting close, but no doubt we’ll see a wave of last minute EHR certifications from EHR vendors. It’s kind of like many of you reading this that are sitting on your taxes and we’ll have a rush of tax filings in the next few days. It’s not a perfect comparison since EHR certification is more complex and there are a limited number of EHR Certification slots from the ONC-ATCB’s, but be sure there are some waiting until the last minute.

It’s also worth considering that I saw one report that talked about the hundreds (or it might have been thousands) of 2011 Certified EHR that never actually had any doctors attest using their software. If none of your users actually attested using your EHR software, then would it make any business sense to go after the 2014 EHR certification? We can be sure those will drop out, but I expect that a large majority of these aren’t really “EHR” software in the true sense. They’re likely modularly certified and add-ons to EHR software.

To date, I only know of one EHR software that’s comes out and shunned 2014 Certified EHR status. I’m sure we’ll see more than just this one before the deadline, but my guess is that 90% of the market (ie. actual EHR users) already have 2014 Certified EHR software available to them and 99% of the market will have 2014 certified EHR available if they want by the deadline.

I don’t think 2014 EHR certification is going to be a differentiating factor for any of the major EHR players. All the major players realize that being 2014 Certified is essential to their livelihood and a cost of doing business.

Of course, the same can’t be said for doctors. There are plenty of ways for doctors to stay in business while shunning 2014 Certified EHR software and meaningful use stage 2. I’m still really interested to see how that plays out.

Eyes Wide Shut: Meaningful Use Stage 2 Incentive Program Hardships

Posted on March 5, 2014 I Written By

Mandi Bishop is a hardcore health data geek with a Master's in English and a passion for big data analytics, which she brings to her role as Dell Health’s Analytics Solutions Lead. She fell in love with her PCjr at 9 when she learned to program in BASIC. Individual accountability zealot, patient engagement advocate, innovation lover and ceaseless dreamer. Relentless in pursuit of answers to the question: "How do we GET there from here?" More byte-sized commentary on Twitter: @MandiBPro.

In my January update on Meaningful Use Stage 2 readiness, I painted a dismal picture of a large IDN’s journey towards attestation, and expressed concern for patient safety resulting from the rush to implement and adopt what equates to, at best, beta-release health IT. Given the resounding cries for help from the healthcare provider community, including this February 2014 letter to HHS Secretary Kathleen Sebelius, I know my experience isn’t unique. So, when rumors ran rampant at HIMSS 2014 that CMS and the ONC would make a Meaningful Use announcement, I was hopeful that relief may be in sight.

Like AHA , I was disappointed in CMS Administrator Marilyn Tavenner’s announcement. The new Stage 2 hardship exemptions will now include an explicit criteria for “difficulty implementing 2014-certified EHR technology” – a claim which will be evaluated on a case-by-case basis, and may result in a delay of the penalty phase of the Stage 2 mandate. But it does nothing to extend the incentive phase of Stage 2 – without which, many healthcare providers would not have budgeted for participation in the program, at all, including the IDN profiled in this series. So how does this help providers like mine?

Quick update on my IDN’s progress towards Stage 2 attestation, with $MM in target incentive dollars at stake. We must meet ALL measures; there is no opportunity to defer one. The Transition of Care (both populating it appropriately, and transmitting it via Direct) is the primary point of concern.

The hospital EHR is ready to generate and transmit both Inpatient Summary and Transition of Care C-CDAs. The workflow to populate the ToC required data elements adds more than 4 minutes to the depart process, which will cause operational impacts. None of the ambulatory providers in the IDN have Direct, yet; there is no one available to receive an electronic ToC. Skilled resources to implement Direct with the EHR upgrades are not available until 6-12 weeks after each upgrade is complete.

None of the 3 remaining in-scope ambulatory EHRs have successfully completed their 2014 software upgrades. 2 of the 3 haven’t started their upgrades. 1 has not provided a DATE for the upgrade.

None of the ambulatory EHRs comes with a Clinical Summary C-CDA configured out-of-the-box. 1 creates a provider-facing Transition of Care C-CDA, but does not produce the patient-facing Clinical Summary. (How did this product become CEHRT for 2014 measures?) Once the C-CDA is configured, each EHR requires its own systems integrator to develop the interface to send the clinical document to an external system.

Consultant costs continue to mount, as each new wrinkle arises. And with each wrinkle, the ability to meet the incentive program deadlines, safely, diminishes.

Playing devil’s advocate, I’d say the IDN should have negotiated its vendor contracts to include penalty clauses sufficient to cover the losses of a missed incentive program deadline – or, worst case scenario, to cover the cost of a rip-and-replace should the EHR vendor not acquire certification, or have certification revoked. The terms and conditions should have covered every nuance of the functionality required for Stage 2 measures.

But wait, CMS is still clarifying its Stage 2 measures via FAQs. Can’t expect a vendor to build software to specifications that weren’t explicitly defined, or to sign a contract that requires adherence to unknown criteria.

So, what COULD CMS and the ONC do about it? How about finalizing your requirements BEFORE issuing measures and certification criteria? Since that ship’s already sailed, change the CEHRT certification process.

1. Require vendors to submit heuristics on both initial implementation and upgrades, indicating the typical timeline from kick-off to go-live, number of internal and external resources (i.e., third-party systems integrators), and cost.
2. Require vendors to submit customer-base profile detailing known customers planning to implement and/or upgrade within calendar year. AND require implementation/upgrade planning to incorporate 3 months of QA time post-implementation/upgrade, prior to go-live with real patients.
3. Require vendors to submit human resource strategy, and hiring and training program explicitly defined to support the customer-base profile submitted, with the typical timeframes and project resource/cost profiles submitted.
4. Require vendor products to be self-contained to achieve certification – meaning, no additional third-party purchase (software or professional services) would be necessary in order to implement and/or upgrade to the certified version and have all CMS-required functionality.
5. Require vendor products to prove the CEHRT-baseline functionality is available as configurable OOTB, not only available via customization. SHOW ME THE C-CDA, with all required data elements populated via workflow in the UI, not via some developer on the back-end in a carefully-orchestrated test patient demo script.
6. Require vendor products adhere to an SLA for max number of clicks required to execute the task. It is not Meaningful Use if it’s prohibitively challenging to access and use in a clinical setting.

Finally, CMS could redefine the incentive program parameters to include scenarios like mine. Despite the heroic efforts being made across the enterprise, this IDN is not likely to make it, with the fault squarely on the CEHRT vendors’ inability to deliver fully-functional products in a timely manner with skilled resources available to support the installation, configuration, and deployment. Morale will significantly decline, next year’s budget will be short the $MM that was slated for further health IT improvements, and the likelihood that it will continue with Stage 3 becomes negligible. Vendor lawsuits may ensue, and the incentive dollar targets may be recouped, but the cost incurred by the organization, its clinicians, and its patients is irrecoverable.

Consider applying the hardship exemption deadline extension to the incentive program participants.

Did Meaningful Use Try to Do Too Much?

Posted on February 12, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

When I was reading Michael Brozino’s post on EMR and EHR about the Value of Meaningful Use, I was hooked in by his comment that meaningful use standards only went halfway. I’m not sure if this was the intent of his comment, but I couldn’t help but sick back and consider if meaningful use missed the mark because it only went half way.

When I think about all of the various features of meaningful use, it really feels to me like ONC and CMS tried to bite off more than they could chew. They tried to be all things to everyone and they ended up being nothing to no one. Ok, that’s not perfectly correct, but is likely pretty close.

Think about all of the meaningful use measures. Which ones go deep enough to really have a deep and lasting impact on healthcare? By having so many measures, they had to water them all down so it wasn’t too much for an organization to adopt. I’m afraid these watered down measures and standards render meaningful use generally meaningless.

Certainly the EHR incentive money has stimulated EHR adoption. However, could this EHR adoption have had even more impact if it would have just focused on two or three major areas instead of dozens of measures with good intentions but little impact?

In many ways, this is just a variation on my wish that EHR incentive money would have focused on EHR interoeprability. As meaningful use stands today, we’ve made steps towards interoperability, but we’re still not there. Could we have achieved interoperability of health records if it had been our sole focus? Instead, we’re collecting smoking status and vital signs which get stored in an EHR and never used by anyone outside of that EHR (and some would argue rarely inside of the EHR).

The good news is we could remedy this situation. ONC and CMS have something called meaningful use stage 3. How amazing would it be if they essentially through out the previous stages and built MU stage 3 on 2-3 major goals? The foundation is there for MU stage 3 to have an enormous impact for good on healthcare, but I don’t think it will have that impact if we keep down the path we’re currently on.

Yes, I realize that a change like this won’t be easy. Yes, I realize that this means that someone’s pet project (or should I say pet measure) is going to get cut. However, wouldn’t we rather have 2-3 really powerful, healthcare changing things implemented than 24 measures that have no little lasting impact? I know I would.

Side Note: Think how we could simplify EHR Certification if there were only 2-3 measures.

CCHIT to Leave the ONC Certification Business

Posted on January 28, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Update: Multiple people sent me the email that was sent to CCHIT certified EHR vendors that details this decision. In the email, along with what’s detailed below, CCHIT suggests a transition to ICSA Labs for EHR certification and talks about a new allegiance with HIMSS to provide new programs and policy guidance including a series of summits and events to support that work. I’m still waiting for an official response from CCHIT and will update the post if they respond.

Update 2: Here is CCHIT and HIMSS press release about the change and also ICSA Labs comments on the change. Drummond Group also issued this response.

I recently got word from a source close to the EHR certification world (yes, that could be just about any EHR vendor or EHR consultant) that CCHIT is about to announce they are leaving the ONC Certification business. I was told that CCHIT will test those that are already in the pipeline, but will not continue as an ONC EHR certifying body. I’d still classify this as a solid rumor for now (I emailed them for comment, but still haven’t gotten a response. I’ll update the post if I do.), but it comes from a reliable source. Plus, CCHIT did just cancel their weekly webinar series. No point in doing the webinar series if you’re not going to be certifying EHR anymore.

Whether the rumor is true or not, it’s worth considering the EHR Certification bodies and what would happen if any of them decide to not go forward with EHR certification. It will likely have a major impact on the meaningful use program.

I don’t think we should be surprised by this decision if indeed it is the case. CCHIT was started years before ARRA and meaningful use. They were created with a cost structure that was higher because they were charging a lot more for their EHR certification when they started. Once ARRA hit, CCHIT was marginalized and as EHR certification was commoditized and codified, CCHIT became irrelevant. Plus, with three new competitors certifying EHR, the prices for EHR certification dropped dramatically.

Furthermore, I think that all of the EHR certifying bodies are finding that 2014 EHR Certification is much more complex and time consuming than the 2011 certification. Yet the price to certify is basically the same. To me, the economics of the EHR certification business were never good.

Think about the business. Let’s say you get paid about $30,000 per EHR certification. There are only 600 customers (at the time we thought it was closer to 300) for your entire business and many of those don’t even pay the full $30k. Enter in 3 competitors and you’re now sharing a market of less than $18 million or $4.5 million per certifying body. Not to mention the stimulus is for only 5 years with many of the EHR vendors likely to consolidate, stop certifying, or go out of business. Plus, EHR certification is not a high margin business and requires expensive government certification. The economics just aren’t that exciting as an entire business.

This rumor is also interesting when paired with the comments I’ve heard that the EHR certification bodies have a backlog of EHR vendors that are trying to get 2014 certified. They’re having to schedule their testing day months out. If CCHIT gets out of the EHR certification business, then that will only increase the delay in 2014 EHR certifications. I wonder if this will lead to another call for a delay in meaningful use stage 2. Can it be delayed now that some have already started MU stage 2?

I’ve never been a fan of EHR certification. I think it represented a lot of cost and very little value to the EHR industry, doctors and patients. I’ll never forget when I asked Marc Probst, Intermountain CIO and member of the ONC committee that worked on EHR certification, why we needed EHR Certification if people had to show meaningful use of the requirements. If you can show meaningful use of a requirement, then the software can certainly do that requirement, no? He answered, “I lost that battle.”

Whether this rumor is true or not, the next couple months are going to be really interesting months for EHR vendors. How many will get across the 2014 EHR Certification line in time? How many will fail in the process? Will the ONC-CHPL be able to keep up? If CCHIT does leave ONC EHR certification behind, what will they do next? Can CCHIT do something to make themselves relevant again?

One EHR Vendor’s Experience with Meaningful Use Stage 2 Certification

Posted on January 3, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

I always love hearing from the CEO of EHR vendors. One that never disappoints is a man that most people in the EHR world have probably never heard of. His name is Michael Archuleta and he’s the Founder and CEO of a company called ArcSys (RedPlanet is their EHR). In response to my article on ComChart not going after meaningful use certification, he sent me a newsletter he recently sent his staff and some other side comments. They provide some real insight into the 2014 certification process and meaningful use stage 2.

Excerpts from the newsletter:

ArcSys has invested heavily in meeting the demands of Meaningful Use Stage 2. Whereas we thought Stage 1 was difficult, Stage 2 has taken substantially more time to meet the requirements.

We are not alone in meeting these challenging complexities. In reading the Internet chatter, there are other vendors who are facing the daunting task at hand.

ComChart Medical Software, has thrown in the towel by saying, “In addition to the Meaningful Use mandates, there continues to be a never ending stream of new mandates such as ICD-10, PQRI, Meaningful Use 2, Meaningful Use 3, SNOMED, ePrescribing, LOINC, Direct Project, health information exchanges etc. As a result of the mountain of mandates, ComChart EMR and the other small EMR companies will have to choose to implement the mandates or use their resources to add “innovative” features to their EMR. Unfortunately, the small EMR companies do not have the resources to do both.”

Obviously, ArcSys does not share this same viewpoint. If we can do it, then it means anyone should have been able to do it, too. We are either smarter (not true) or we had a superior software design from the beginning (probably quite true). The first round of software development has now been completed and we are prepared for certification. Our certifier, the Drummond Group, has a backlog of systems to be tested and have given us a mid-April test date. Having completed this development, we know with great precision what each doctor will have to do in order to meet MU2. And, yes, it will be difficult.

There are 37 testing “points” that we have focused on. It took us two months to do 36 of these points and another two months to do the remaining point (clinical quality measures). Many of the testing points had literally hundreds of scenarios to evaluate. There were situations we would discover after working for weeks that necessitated going back to the beginning and having to start over on retests.

Now for some really interesting bullet points on meaningful use stage 2 certification:

ArcSys has to be the tiniest company on the planet seeking MU2 certification.

Yes, I dislike the extra burdens being placed on providers for MU2.
Yes, I dislike the vague (non-existent?) guidelines on how to properly use SNOMED, Rxnorm, and LOINC.
Yes, I dislike the committees who dream up measures and certification rules that have little relevance to how docs like to treat and interact with patients. Do they really believe MU2 and seeing 40+ patients/day can co-exist??
Yes, I have written every line of code for our product to handle MU2 and I know of flaws and weaknesses the testing tools are ignoring.
Yes, I hate being pulled away from being able to work on software enhancements.
Yes, we were naive in thinking that MU2 would take as much time as MU1 to develop and test. It was easily 10 times more complicated.
Yes, I dislike wading through the Google/JIRC posts to see what other hapless souls like me our stumbling for answers regarding certification.
Yes, it is nearly impossible to read any document produced by HL7.org and find helpful guidelines.
Yes, I dislike the Cypress testing tool.
Yes, I dislike the XML bloat for reporting measures and transporting patient data.

So, why do we continue? Simple. We made a commitment to our client base who likes our service and support. And, in the end, we’ll be as conversant as anyone on the ins and outs of MU2.

How’s that for a real look at some of the nitty gritty EHR vendors face when it comes to 2014 Certification and meaningful use stage 2?