Eyes Wide Shut: Meaningful Use Stage 2 Incentive Program Hardships

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.

About the author

Mandi Bishop

Mandi Bishop

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.


  • Your blog is really awesome & i have really enjoy it . While there are some who will game the system and others are surprised to learn the MU checks don’t exceed their costs to move to current technology, there are others who have figured out how to use this as, I believe, it was intended. That is to be a Launch pad to making patients own more of their overall health.

  • Your blog is really awesome.While there are some who will game the system and others are surprised to learn the MU checks don’t exceed their costs to move to current technology, there are others who have figured out how to use this as, I believe, it was intended.

  • Glad you enjoy it, Elliot – thanks for the compliment! While I do, indeed, wholeheartedly agree with the spirit of Meaningful Use, the challenges I’m facing in the trenches with a variety of provider types and disparate EMRs certainly give me pause as to when we will achieve the “meaningful” portion of this program.

    The world likely looks very different from a green-field implementation standpoint, especially with a small(er) provider. The EWS series profiles a very large delivery network, so it is definitely not representative of everyone’s experience.

    However, as more and more independent general practitioners join large delivery networks in order to save on health IT and administrative costs, I believe more of the industry will feel these pains.

  • Hello Mandi, very insightful writing I’ve read in a while.

    While hardships to push penalties is ok, what happens to the actual incentives. So providers lose 2014 incentive or just push it back one year and therefore get the full set of incentives?

    If I read this correctly, ‘…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’ – it implies you lose this year’s incentive.

  • Excellent blog – there is nothing like a real world scenario to describe how onerous MU can be for the customer.

    I agree with all your recommendations and would add some:
    * Require the certified version actually be in production with attested use by x number of providers. While CCHIT required this for their CCHIT certification, ONC-ATCB does not require actual use. As a result, a lot of products are getting certified (and big “we’re certified” announcements made) when in reality the vendor cannot deliver the product yet – either to new customers or existing ones.
    * There should be a public forum for customers to report issues with their certified product not actually meeting MU and CMS should respond in this forum, much as they do their FAQs. I found a certain free EHR that was certified for MU1 but could not do medication reconciliation. It was a known issues reported on and responded to in their user forum. I submitted a question about it to CMS and (while I never received a response from CMS) the vendor corrected the issue within a couple of weeks.
    * Rather than just publish timelines for a vendor to upgrade their customers, etc., I believe minimum timelines should be required and vendors should have to pay a penalty if they are not met.
    * The current Cost Statement requirement should be tightened and enforced – vendors should be required to publish the EXACT costs of any additional software or service needed to meet MU and this information should be included in ONCCHPL’s listing of certified EHRs.

    In short, I think CMS would be doing a service to providers if they would spend less time (and money) coming up with more requirements on the providers (and vendors) and more time (and money) enforcing the intent of the EHR program. The current structure lends itself to rewarding big vendors that can churn out new programming code and marketing but can’t actually get their customers up an running cost effectively on the necessary software and services.

    As a vendor it pains me to do it right and lose business to other vendors that make empty promises and win the business – only for the customer to then become stuck because they have too much sunk costs or too little time to move. Fortunately for us, word spreads and we don’t lose to the offending EHRs much anymore – but it still creates a nightmare for their stuck customers.

  • Chandresh – yes, you lose this year’s incentive.

    Catherine – excellent additions, and absolutely accurate. I couldn’t agree more than CMS should evaluate whether the intent of the Meaningful Use mandate is being met, and take the opportunity to assimilate the feedback from the provider and vendor communities prior to forging ahead with the latest round of requirements.

  • Mandi:
    What a wonderful commentary on the full state of affairs. In reality, hospitals in essence are doomed on this front, unless of course they have already purchased the PCP’s and Specialists. Even in this scenario, it is is not all peaches, the vendor in one case charges interface fees for every single practice, all the labs, diagnosis centers, and any third party outside of that Hospital Group/ACO (FILL IN THE BLANK) and thus, ultimate goal of MUII is not really practical.

    Not a pretty story, not what CMS intended, but reality all the same.

    The part the Government missed is, that the standard should be free, not require any development, and work in Batch, real time and ad-hoc (end user action). I agree with your point that vendors passed without real live end users. Failure on the part of the end user to due diligence on installations and end user counts, puts some fault on the end user (Note: How can End Users know what the software should or should not due, that was the point of the certification to begin with). Failure of the Government to provide strict requirements to cost and interface communication and methodology lies strictly on CMS. Failure on the Vendor to meet the specification, and to in essence lie and fraud the system by not truly providing the functionality and simply tricking the test, lies squarely on the unethical vendor.

    CMS bought into the idea, but not really thought out the implementation issues. This was not all on CMS, they did their best, but with all the committee’s, meetings and third party influence/interests, they simply missed one simple item. Communications and integration is core to product function and not a integration or add-on product. Yes the standard is free (CDA, HL7), but the methodology to integrate, not even close. In reality, the majority, over 90% of Ambulatory, mine included, requires interface setup to work in batch or real time. Out of the box, they can generate the files and transfer them via ad-hoc. That as you pointed out is debatable for some of the vendors in this story, as the files themselves are not even able to be generated for summary of care as needed in this thread/story.

    Bottom line it is a mess, and the IT costs for security, IT Support, third party support, tool kits, etc… are ridiculous and in one way or another passed on to the end user. In stage III they want to implement Decision Support. This one feature will be a death nail to any vendor with under 1000 end users or deep pockets on cost alone. That sounds fine, but what happens to all those providers in this category who are happy using the certified EHR they purchased, and now CMS screws them, on one requirement and they are forced to pay a high cost (from 5K-20K or more per provider) to convert the existing EHR, not because they are not happy, just because of Government Bureaucracy.

    I see many end users not even bothering, just don’t take the carrot (Incentives 2 and 3) and accept the stick (Penalties) as just a cut to already dwindling payment models.

  • Brendon – eloquently stated. I haven’t touched on the issues we face regarding CDS, or the potential patient-safety perils of implementing CDS modules developed by EHR vendors in partnership with Big Pharma organizations (ahem, CareFusion, $41B in fines for kick-backs).

    We’ll see what the new legislation governing the EHR incentive program brings to bear. I’m thinking/hoping many of these issues will become moot points in short order.

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