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David F Carr
David F Carr
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Meaningful Use Deadlines Clash With Software Best Practices

Hospitals find themselves implementing new releases of EHR software, certified to 2014 standards, almost as soon as vendors release certified versions. That's almost like implementing Windows 8 immediately after release.

When federal regulators announced plans to stretch the schedule for electronic health record (EHR) implementation under the Meaningful Use incentives program, they said one of the complaints they were responding to was a compressed timeline.

By the time requirements for software capabilities intended to enable Meaningful Use Stage 2 were finalized, vendors had too little time to translate them into working software, and healthcare enterprises had too little time to test, configure, and deploy the software. Those who managed to do so anyway -- or are well on their way to implementing software certified to the 2014 requirements -- may have felt a little foolish after learning of the proposed rule to allow users of software meeting the 2011 edition of the software to continue to qualify for the program.

Given more notice, most would have chosen to take the implementation a lot more slowly. One of the big reasons Meaningful Use is so challenging is the conflict between the program's ambitions for rapid change and the more cautious software implementation schedule favored by large enterprises, including hospital systems.

[Familiar pattern? Read ICD-10 Remains High Priority Despite Delay.]

In a joint announcement last week, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT also said they would extend the Stage 2 phase of the program by a year, through the end of 2016, giving the healthcare industry more time to absorb and optimize the technology it has already implemented. Stage 3, which is expected to focus more on the outcomes that can be achieved with technology than on new IT requirements, would then begin in 2017.

It's more complicated than that, because the program really has two halves. One is the certification of software that meets the requirements of each Meaningful Use stage, known as certified electronic health records technology (CEHRT). The other is a set of quality metrics healthcare organizations are expected to meet to show they have used the technology in a meaningful way. Although this is the year of Meaningful Use Stage 2 for those organizations that started with Meaningful Use Stage 1 back in 2011 or 2012, organizations just now entering the program start at Stage 1. At the same time that they formulated their 2014 technology requirements, regulators adjusted the Stage 1 requirements to match what organizations ought to be able to accomplish with 2014 editions of the software.

To "clarify" the proposed rule, CMS had to publish a matrix of requirements that will now apply depending on whether an organization has implemented 2011 CEHRT, 2014 CEHRT, or a mix of the two -- and also depending on whether the organization plans to attest for Stage 1 or Stage 2 compliance this year. This is what that looks like:

Table 1: How Required Metrics Map To EHR Certification Year

Current Stage 2011 CEHRT 2011/2014 CEHRT 2014 CEHRT
Stage 1 2013 Stage 1 objectives and measures* 2013 Stage 1 objectives and measures*
2014 Stage 1 objectives and measures*
2014 Stage 1 objectives and measures
Stage 2 2013 Stage 1 objectives and measures* 2013 Stage 1 objectives and measures*
2014 Stage 1 objectives and measures*
Stage 2 objectives and measures*
2014 Stage 1 objectives and measures*
Stage 2 objectives and measures
*Only providers that could not fully implement 2014 Edition CEHRT for the reporting period in 2014 due to delays in 2014 Edition CEHRT availability.

Dr. Robert Wah, chief medical officer at consulting firm Computer Sciences Corp., welcomes the "encouraging signs of flexibility" demonstrated by the extension. He suggests every organization needs to study the proposed rule in detail to understand how it applies to them. Although the proposal still has to pass through a 60-day comment period, the proposal is a clear signal that the deadlines will be extended by at least this much.

True, the timing is such that organizations in the middle of the process of deploying technology or attesting for Stage 2 can't afford to slow down. However, the proposed rule suggests that the aim is to provide relief for organizations that were unable to obtain 2014 certified software in time to meet this year's Meaningful Use goals.

"The people who are on schedule will be fine," says Wah. "But there are a large number of people who will benefit from this flexibility."

Nevertheless, the ruling generated complaints from the American Medical Association, saying the requirements are still coming too fast, and the National Partnership for Women and Families, worrying that the promised benefits of health IT are being delayed. The College of Healthcare Information Management Executives (CHIME) welcomed the rule change but urged CMS to finalize it as quickly as possible.

As part of my research for our Healthcare IT Priorities Survey report, I recently spoke with CHIME board chair Randy McCleese, CIO of St. Claire Regional Medical Center, about the forced march that hospitals

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participating in the Meaningful Use program find themselves on and how different that is from how an enterprise normally deploys technology.

"We got our 2014 certified software, but we've also gotten five major patch fix updates since that was originally released," he told me a few weeks ago. With each of those releases, his staff has to go through a cycle of testing, so "we're busy constantly doing that."

Many of the patches from Meditech, St. Claire's EHR vendor, were also driven by regulatory requirements -- even after securing certification, Meditech continued to get feedback that the way its developers had implemented certain requirements didn't match the regulators' intent, forcing further revisions, McCleese said.

Most CIOs have something close to a hard-and-fast rule against being the first to deploy a new version of any piece of software -- better to let someone else go first and be the one to find all the bugs. If they install new software at all, most prefer to do so first in a test environment where they can debug the back-end interfaces and allow their early adopters to experiment with the user interface so they can help with the rollout and training when the time comes. That's why so many organizations always seem to be running the last version of Windows, or SharePoint, or most any on-premises installed software you can name.

Of course, this is one of the arguments in favor of cloud software in which the vendor takes turnkey responsibility for the back end, and all users can be kept up to speed on the latest and greatest front-end features. That's a great argument in favor of using cloud software for something like enterprise social networking, where user expectations are shaped by the latest features added by Facebook. However, although cloud EHR software is gaining popularity among medical practices, it has yet to make a dent in the hospital market. Given that errors in medical records data can lead to life-and-death consequences, the conservatism of hospital IT leaders is understandable. But the architects of the Meaningful Use program, in their impatience for change, have tended to force a cloud-like implementation schedule on an industry that's not ready for the cloud -- at least not for core EHR functions.

Hospitals found themselves implementing new releases of software, certified to the 2014 standards, almost as soon as the vendors released the certified versions. That's almost like implementing Windows 8 immediately after it was released.

As the CIO of a midsized Kentucky hospital, McCleese would have been unlikely to rush a new release of an EHR into production and endure the flurry of patches that followed, if not for the looming Meaningful Use deadlines. In contrast, St. Claire is likely to adopt a Web-based practice management product that Meditech plans to release in 2015 "but we've already said it will be at least 2017 before we install that," he told me. "With the regulatory requirements, we don't have a choice."

Has meeting regulatory requirements gone from high priority to the only priority for healthcare IT? Read Health IT Priorities: No Breathing Room, our latest digital issue.

David F. Carr oversees InformationWeek's coverage of government and healthcare IT. He previously led coverage of social business and education technologies and continues to contribute in those areas. He is the editor of Social Collaboration for Dummies (Wiley, Oct. 2013) and ... View Full Bio
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