You can hear the sigh of relief—albeit mixed with a bit of uncertainty-driven anxiety—as physicians await publication of the final rule that will modify meaningful use in 2014. By relaxing the timeline, the government has finally acknowledged what so many stakeholders have been arguing for a while: Stage 2 and upgrading to a 2014 Certified EHR simply required too much of providers, too quickly. The paltry number of Stage 2 attestations to date is evidence enough—by May, only 50 physicians had attested to Stage 2; by June, just 447 had succeeded; and by July (mid-way into the year), the number had reached only 972. To put these numbers in context, over 378,000 providers have earned EHR incentives for Stage 1.
The major challenges that prompted the government’s reconsideration of the meaningful use timeline are reflected in the 1,184 comments submitted to CMS—some of which express frustration with the demands of the program in general, but almost all of which wholeheartedly support the proposed changes. (My comments, submitted on behalf of SRS physicians, are available here.) The following are the most common challenges cited:
- Availability of 2014 Certified EHR Technology (CEHRT) – But it’s not just about the products that are not yet certified or about vendors with insufficient resources to keep up with the demand for implementations. Many of the products that have been certified were rushed out under overly aggressive and unrealistic timeframes, which has left physicians faced with not-ready-for-primetime software.
- Overestimation of market readiness for interoperability – Sufficient infrastructure is not in place yet, so even physicians who have implemented the DIRECT messaging capability cannot find enough “trading partners” with whom they can connect to share information.
- Dependence on non-participating parties – It takes an extraordinary amount of effort to successfully coordinate with labs, radiology providers, long-term care facilities, and registries, who are not required to conform to standards promulgated under meaningful use.
- Reluctance of patients to embrace portal utilization – The two portal measures (patients accessing clinical information and sending messages to physicians) are cited by many commenters as the major obstacle to MU success. Changing patient behavior in this regard is turning out to be even harder to accomplish than previously anticipated.
- Excessive workflow challenges – Meaningful use necessitates operational changes to practice workflows that are, in the words of one commenter, “daunting, at best.”
The options proposed in the rule are summarized in a handy CMS Decision Tool and include reporting Stage 1 again, instead of Stage 2, and attesting using either a 2011 or 2014 CEHRT.
So what can physicians expect and what would be a good strategy to pursue as they wait for the final rule? CMS is promising—or at least hoping—to publish the final rule in early September. The 60-day comment period ended on July 21, and CMS is obligated to read and consider all of the comments before issuing the final rule. However, I think it is reasonable for physicians to assume that the final rule will be at least as flexible as the proposed rule—maybe even more so. CMS has been asked by many commenters to definitively spell out the conditions under which physicians could avail themselves of the various reporting options, which would address the uncertainty created by the lack of clarity in the proposed rule.
In the meantime, physicians should plan to attest for any quarter during which they have met all of the requirements under one of the options provided for in the proposed rule. It can even be a quarter that precedes the publication of the final rule. They should then aggressively turn their attention to upgrading to 2014 CEHRT—if they have not done so already—and to preparing for Stage 2. Remember: as flexible as the rule may be, it only offers a 3-month reprieve. Physicians who were to be at Stage 2 in 2014 must now be ready to start a full year of reporting on Stage 2, using a 2014 CEHRT, on January 1, 2015.
I’m Scott Ciccarelli, the new CEO at SRS. Although EMR Straight Talk is industry-focused—not about SRS—in my first blog post I thought I would tell you a bit about my SRS experience so far—I can sum it up in three letters: ETP.
The “eager to please” culture permeates everything at SRS. Each individual I’ve had the pleasure to meet so far is bursting with dedication and a relentless desire to help—each other, our clients, and me. What a support network, where every desk is literally a help desk!
This commitment to ETP is the reason SRS has the highest customer satisfaction ratings in the industry; however, we realize that we cannot rest on yesterday’s success. Like all industry vendors, we work in an ever-changing and uncertain landscape, making use of rapidly developing—and sometimes unpredictable—technologies to cope with the onslaught of government regulations. The challenge for every vendor is to develop products that not only satisfy the government requirements, but also meet the clients’ needs for flexible and efficient solutions. SRS remains dedicated to this goal. If there is anything that sets SRS apart, it is our understanding that even for IT companies, it ultimately all comes down to people—after all, technology is created by people, and it should serve the people who use it. So, let me tell you a little bit about the people who are leading the charge at SRS:
- Bob Harmonay, our COO, has an unrivaled passion for exceeding client expectations that inspires his team daily—and that is largely responsible for our Best in KLAS customer service and support ratings.
- Joe Flynn, SVP of Sales & Marketing, champions communication as the path to growth—for SRS and for each of our clients, whom he and his account team ensure are informed and prepared to reach their practice goals.
- Lynn Scheps, VP of Government Affairs & Consulting Services, is a leading resource on meaningful use and other government initiatives. She represents physicians’ interests with government officials and develops strategies to help practices respond effectively to the ever-evolving demands of government programs.
- Jack Walsh, EVP of Strategy & Business Development, is responsible for strategic planning, building and nurturing partner relationships, and evaluating opportunities for enhancement of our product platform.
- Peter Bennfors, our CFO, oversees all financial activities, from accounting to regulatory compliance. His experienced hand at the helm ensures that SRS will stay financially seaworthy and able to weather storms for many years to come.
I am truly grateful to have such a powerful leadership team in place. I look forward to adding my 20 years of Fortune 500 and HCIT experience to the mix and finding new ways to achieve our goal: helping physicians and other professionals provide the very best healthcare.
Please check back here every couple of weeks—or subscribe in order to receive new blog notifications—for no-holds-barred discussions about industry issues, company insights, and ways to keep making things better. I’ll also be featuring some very special guest bloggers, starting with the next blog post on August 1!
I’d like to thank everyone who has already made me proud to be part of SRS. Now I look forward to meeting and hearing from all of you readers. Tell me what you want to hear about. I’m all (ETP) ears.
After 17 years as the founder and CEO of SRS, I am transitioning to the role of Senior Advisor. I am extremely proud of the position that SRS has come to occupy in the healthcare technology industry, and as I hand the company reins over to Scott Ciccarelli, a seasoned executive with extensive healthcare experience, I am confident that SRS will continue to make its mark.
Writing the EMR Straight Talk blog has been one of my passions since its launch on February 17, 2009, as President Obama signed the Economic Stimulus Package making “meaningful use” a household term. The purpose of the blog has always been to educate readers and to stimulate critical thinking about the issues that impact physicians, so the number and intensity of comments from readers has been particularly rewarding.
For more information about the transition at SRS, read today’s press release. I hope you will continue to read EMR Straight Talk as the blog undergoes its own transition.
Thank you for reading.
Best wishes for your continued success,
Year after year, physicians live for months with the uncertainty and angst of threatened, often draconian, Medicare reimbursement cuts born out of the Sustainable Growth Rate (SGR) budgeting formula. And every year, intense lobbying and complex negotiations lead to short-term patches that maintain or slightly increase reimbursement rates—these solutions are commonly referred to as the Doc Fix. This year’s fix is set to expire at the end of March, which would leave physicians facing a 23.7% reduction—but on Thursday, a bipartisan piece of legislation proposed a repeal of the SGR and the creation of a new payment model that would reward quality, rather than volume of care provided. All that’s left now is to figure out how to fund the $128 billion price tag over the next 10 years.
Although I haven’t read the 200-page bill, the following is a summary of its major provisions:
- The SGR fix would increase Medicare physician reimbursement rates by 0.5% annually for the next 5 years, i.e., through 2018. This would provide income predictability and stability for providers.
- 2018 rates would be maintained through 2023.
- From 2024 on, physicians who participate in Alternate Payment Models would see a 1% annual increase; non-participants would receive 0.5% increases.
- It would create a new payment system called MIPS (Merit-Based Incentive Payment System) by 2018, which would roll up meaningful use, PQRS, and the Value-Based Payment System into one program that would tie physician reimbursement to quality and cost. Physicians would be assessed in 4 areas:
- Quality: based on current and future quality measures from the PQRS and Meaningful Use programs
- Resource use: assessment of cost structure using a method similar to that currently in use in the Value-Based Payment Program
- Meaningful Use: satisfying current meaningful use requirements demonstrated by use of a certified EHR
- Participation in practice improvement activities: a new area of measurement related to clinical improvement.
- Physicians would receive a composite score on all of the above. Based on total score relative to other physicians, they would receive either:
- A negative adjustment of up to 4% in 2018, 5% in 2019, 7% in 2020, and 9% in 2021
- No adjustment
- A positive adjustment of as much as 3 times the maximum negative adjustment for that year.
- The new payment system would provide additional incentives (5% per year from 2018 to 2023) to providers who derive a substantial part of their income from alternative payment models that base payment on quality assessment and financial risk sharing rather than volume of services provided, (e.g., ACOs, Medical Homes, or other new healthcare delivery models).
- It would encourage cost savings by incentivizing care coordination and adherence to Clinical Decision Support (CDS) mechanisms and Appropriate Use Criteria (AUC) aimed at reducing unnecessary testing—specifically in the area of advanced diagnostic imaging:
- Effective 2017, physicians would be paid for advanced diagnostic imaging only if the claim shows consultation with CDS mechanisms and AUC.
- Effective 2020, the 5% of physicians with the lowest adherence rates would require prior authorization for such tests.
- Beginning in 2015, patients would have access to quality and cost data regarding individual physicians that would be made available on the Physician Compare Site.
MIPS would rely heavily on quality measurement, data sharing, and interoperability, so one thing is abundantly clear: Robust EHRs and extensive data management capabilities will be critical tools for physician success in the future, even more so than they are today.
I believe that 40% of past attesters will give up on meaningful use. To understand the troubling trends that lead to this conclusion, read my Readers Write column on HIStalk.
For many physicians pursuing the EHR incentives, 2014 means moving on to Stage 2 of meaningful use. Stage 2 is much more complex than Stage 1, with higher thresholds for most Stage 1 measures; core (i.e., mandatory) requirements that were formerly menu (i.e., optional); and totally new measures related to interoperability and patient engagement that will require revised workflows. It’s not too early to start learning about Stage 2, and I would suggest that physicians and their staff members take advantage of the abundant educational opportunities that already exist. CMS has produced helpful tipsheets and guides for providers, and you should expect your EHR vendor to offer comprehensive training programs on Stage 2. Another good way to learn about the new requirements is to attend a webinar—there are many, and I invite you to attend one of my company’s webinars that will prepare you well for 2014.
In the meantime, test your basic knowledge of 2014 and Stage 2 by taking this quiz. If you have any questions of your own, please comment below and I will be happy to respond.
Amid the abundant (and yet unanswered) pleas from all quarters to extend or delay Stage 2 comes some potential good news about the scheduling of Stage 3: It’s becoming clearer and clearer that Stage 3 won’t start for anyone before 2017—at the earliest.
Although I have not seen any formal announcements by CMS or ONC confirming this, a recent legislative update from the EHRA (the HIMSS EHR vendor association) reported that the proposed rule on Stage 3 is not expected until late 2014. There are many steps and a defined timeline that transpire between the release of a proposed rule and implementation of the final regulations in the field. First, there is a 90-day comment period, during which all stakeholders have the opportunity to express their support and/or concerns about every aspect of the proposed rule. Then, the government needs another 90 days or so to consider each comment and create the final rule, in which it responds to these comments. That takes us to mid-2015. To give the EHR vendors anything short of 18 months to complete product development, test usability, deploy their upgraded software, and train their clients would meet with overwhelming resistance. Implementation of Stage 3 before 2017 would be highly unlikely.
This breathing room is a good thing for physicians. As I have discussed in prior EMR Straight Talk blogs, meaningful use has essentially stifled innovation by driving EHR vendors to focus the lion’s share of their development efforts on government requirements. Now physicians will benefit from the vendors’ ability to deliver the innovative workflow enhancements that providers need, and they will have time to hone their workflows to more efficiently meet the government’s requirements.