As you have likely heard, CMS issued the final rule on changes to the EHR Incentive Programs for 2014. The CMS press release is available here: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-08-29.html, and I am attaching the full 90-page final rule to this email.
The very bottom of the press release has a table outlining all options for 2014 attestation, which I have copied at the end of this email; please pay special attention to the asterisk indicating which options that are only available to “providers that could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability.”
Although the release states that the rule “allows health care providers more flexibility in how they use certified electronic health record (EHR) technology (CEHRT) to meet meaningful use for an EHR Incentive Program reporting period for 2014,” we believe this flexibility will only benefit those providers who were affected by delays caused by an EHR vendor (although not necessarily their own EHR vendor; see #5 below):
“Therefore, we stress the delay in 2014 Edition CEHRT availability must be attributable to the issues related to software development, certification, implementation, testing, or release of the product by the EHR vendor which affected 2014 CEHRT availability, which then results in the inability for a provider to fully implement 2014 Edition CEHRT.” (p. 42 of attached document)
The main scenarios we believe would allow a provider to use the provisions of this final rule (all quotes reference the page number in the attached document):
1) Your EHR vendor did not receive 2014 edition certification.
“[W]e proposed the options for using CEHRT due to the overwhelming number of providers who informed us they could not meet the objectives and measures of meaningful use with 2014 Edition CEHRT because, for example, they…were waiting for EHR vendor certification”(40)
2) Your EHR vendor received certification, and you attempted to obtain the certified version, but were delayed for reasons beyond your control (such as an installation backlog and no ability to move yourself up the queue).
“Obviously, those providers still waiting for installation of 2014 Edition CEHRT represent the most concrete example of those able to use the CEHRT options because it represents the clearest illustration of both a 2014 Edition CEHRT availability delay and lack of full implementation. (46)
“However, we disagree with these commenters to the extent the changes proposed somehow give providers that waited until the last minute a “free pass”… Many providers had no control over their position in their vendor’s queue for CEHRT installation, no influence on a product’s development timeline, and no participation in the product’s movement through the certification process. All of which may have also contributed to the overall delay in 2014 Edition CEHRT availability.” (22)
3) Your EHR vendor received certification, but you either did not install it or installed it and cannot use it, because there were serious errors or problems in the certified version that made it unusable for you or unsafe for your patients.
“Rather, providers with 2014 Edition CEHRT installed may nonetheless face a 2014 CEHRT availability delay because they are waiting for vendor software updates, or the software itself is presenting problems with functionality, or when the software does not yet contain all required components. This also may include situations where a problem with the software presents a safety issue, such as when a drug allergy or drug interaction clinical decision support does not function properly, or cases where the vendor identified a functionality problem and sends out patches to fix the problem, requiring the provider to wait until the issue is resolved to use the software…So, although we cannot list every possible scenario, installed 2014 Edition CEHRT with delayed or missing software updates, or cases where the software itself renders a provider unable to reliably use the software would be permissible reasons to use the CEHRT options because such issues are considered to be a 2014 Edition CEHRT availability delay.” (46)
4) You work in a setting that utilizes multiple interrelated systems, and although the 2014 certified edition of your EHR was available and/or installed, full implementation was delayed because you were unable to upgrade another dependent or integral system.
“We also understand that the delay in availability may limit a provider’s ability to fully implement 2014 Edition CEHRT across the facility. For example, a hospital may have different systems in multiple settings, which all require an update and integration.” (13)
5) You are unable to meet the 2014 Summary of Care measure requiring that 10% of your outgoing referrals be sent electronically, because the providers you refer to cannot receive these electronic summaries (my emphasis added in the quote below, as I think this option will require significant documentation, and what will be expected is not yet clear).
“We acknowledge referring providers may not be able to meet the summary of care measure in 2014, if receiving providers they frequently work with have not upgraded to 2014 Edition CEHRT. We therefore believe a limited exception is warranted for providers who could not meet the threshold for the Stage 2 summary of care measure requiring the transmission of an electronic summary of care document for more than 10 percent of transitions or referrals because the recipients of the transitions or referrals were impacted by issues related to 2014 Edition CEHRT availability delays and therefore could not implement the functionality required to receive the electronic summary of care document. Therefore, we consider the inability to fully implement to extend to those providers for the summary of care document measure at 42 CFR 495.6 (d)(14)(ii)(B) for EPs and (l)(11)(ii)(B) for eligible hospitals and CAHs. A referring provider under this circumstance may attest to the 2014 Stage 1 objectives and measures for the EHR reporting period in 2014. However, the referring provider must retain documentation clearly demonstrating that they were unable to meet the 10 percent threshold for the measure to provide an electronic summary of care document for a transition or referral for the reasons previously stated. (44)
More interpretations of this rule will certainly come out over the next few weeks and months, but at this point, we believe that most Eligible Professionals outside of hospital systems who currently have a 2014 certified edition of their EHR installed (or who chose not to install it for reasons other than #3 or #4 above) and were scheduled to attest under Meaningful Use Stage 2 may not use the provisions in this rule, except as explained in #5 above.
If you do not currently have the 2014 certified edition of your EHR and want to use the provisions of this rule, you would need to attest that you “could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability,” and you would need supporting documentation of these delays in the event of an audit.
The following scenarios WOULD NOT constitute a “delay in availability,” and so would not allow you to use the provisions of this rule:
1) You did not upgrade to or buy a 2014 certified edition of your EHR due to financial considerations, such as the price of licensing or installation, or the business cost of implementing workflows.
“[P]roviders that did not fully implement 2014 Edition CEHRT due to financial issues, such as the costs associated with implementing, upgrading, installing, testing, or other similar financial issues, would not be able to use the options for CEHRT for the EHR reporting period in 2014.” (42)
2) Your implementation delays were not caused by an EHR vendor.
“Finally, we do not find situations stemming from a provider’s inaction or delay in implementing 2014 Edition CEHRT sufficient to use one of the CEHRT options. These situations include providers waiting too long to engage a vendor or a provider’s inability or refusal to purchase the requisite software update. Such circumstances would not be permissible reasons to use the CEHRT options because they did not stem from a 2014 Edition CEHRT availability delay.” (45)
3) You are unable to meet some Stage 2 measures, including those measures that are out of your control (especially the patient portal/patient engagement measures).
“[I]ssues related to the meaningful use objectives and measures do not constitute an inability to fully implement 2014 Edition CEHRT. Several commenters mentioned that although 2014 Edition CEHRT was available, fully functioning, and implemented, they wanted to attest with one of the CEHRT options because of issues relating to one or more Stage 2 objectives and measures, such as the inability to meet certain measure thresholds which increased from Stage 1 to Stage 2, an overall objection to Stage 2 measures generally, or concerns with measures believed to be outside a provider’s control –– such as an inability to obtain a beneficiary’s e-mail address. Again, we proposed alternate options only for those providers who could not fully implement 2014 Edition CEHRT for a full EHR reporting period in 2014 because of issues related to 2014 Edition CEHRT availability delays. We did not propose these options in order for providers to be exempted from meeting Stage 2 measure requirements.” (42-43)
“We stress that other issues related to objectives and measures, such as a failure to meet a measure threshold, or failure to conduct the activities required to meet a measure, will not be considered a suitable basis to use the CEHRT options outlined in this final rule.” (44)
4) You have experienced staff turnover that has delayed your training and implementation.
“Next, we find staff changes and turnover to be an insufficient rationale for a provider to use the CEHRT options. Some commenters explained that circumstances such as the termination or attrition of staff rendered them unable to train new staff in time to implement 2014 Edition CEHRT. However, we did not intend such rationale to be permissible. Rather, references we made in the proposed rule regarding the inadequate amount of time to train staff stemmed, again, from the fact that EHR vendors were delayed in installing 2014 Edition CEHRT, which, in turn, gave providers little to no time to train their staff on the new software. We consider staff turnover and changes, as well as any other similar situations, to be issues frequently encountered in the normal course of business and therefore insufficient grounds for a provider to use the CEHRT options. (45)
Below is CMS’s table of all CEHRT systems available for 2014 attestation, and the objectives and measures you may use with each system:
| If you were scheduled to demonstrate: | You would be able to attest for Meaningful Use: | ||
| Using 2011 Edition CEHRT to do: | Using 2011 & 2014 Edition CEHRT to do: | Using 2014 Edition CEHRT to do: | |
| Stage 1 in 2014 | 2013 Stage 1 objectives and measures* |
2013 Stage 1 objectives and measures* -OR- 2014 Stage 1 objectives and measures* |
2014 Stage 1 objectives and measures |
| Stage 2 in 2014 | 2013 Stage 1 objectives and measures* |
2013 Stage 1 objectives and measures* -OR- 2014 Stage 1 objectives and measures* -OR- Stage 2 objectives and measures* |
2014 Stage 1 objectives and measures*
-OR- 2014 Stage 2 objectives and measures |
* Only providers that could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability.
While we do our best to interpret the information as it is written, our analysis is neither exhaustive nor authoritative. Each provider must make their own interpretation of the rules and regulations before deciding if or how to attest.
Please feel free to call or email us with any questions you have about this information or Meaningful Use in general, and we will do our best to help you.