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EHR and Stage 2 Meaningful Use: The Future Is in the Cloud

by Dan Haley, SVP and General Counsel

It has been tough for we health IT types to plan our calendars for the fall, with rumors rampant about when the Meaningful Use Stage 2 final rules would drop. Early August? Late September? Before the end of the year? Nobody knew for sure.

Happily, Thanksgiving is safe. Stage 2 is now more than a week old, and many initial reviews are in.

Most go something like this:

  • ‘Thank God for the delay to 2014 (though even that is going to be awfully tough to meet)’
  • ‘Good move ratcheting back on the patient engagement requirements (though even that is going to be awfully tough to meet)’
  • ‘We’re all for interoperability, but let’s just slow down on that a bit too…’

Our point of view is different. It arises from and underscores the strength of the cloud-based service model as compared to the increasingly anachronistic software delivery model. Put simply, the balance that ONC and CMS were forced to strike on Stage 2 proves that the future of health information technology (HIT) is in the cloud.

Don’t get me wrong. There's plenty we are happy to see in Stage 2:

  • batch attestation
  • tighter requirements around transitions of care
  • enhanced patient engagement
  • clear and unambiguous statements coming from ONC about increased interoperability
  • decreased tolerance of vendor and system silos (“walled gardens,” in ONC parlance)

But all of those things come packaged with significant implementation delays and diluted standards that reward technological laggards at the expense of industry innovators and forward-leaning care providers who were ready, willing, and able to meet tougher measures by the original proposed 2013 implementation deadline.

Several commentators have remarked on the balance that the agencies struck between the imperative to drive up EHR use rates (thus: lower standards) and the Congressional mandate to ensure such participation is “meaningful” (thus: higher standards). The problem inherent in this balancing is that it necessarily accommodates the laggards at the expense of the innovators. Worse, by accepting the necessity of such a “balance,” the government implicitly buys into the twin fallacies that the laggards rely upon to justify their continued calls for delay and dilution: that the proposed deadline was unachievable and the proposed standards unattainable. It just isn’t so.

Delayed implementation = delayed progress

Here’s a great comment by CMS from its final rule in response to the calls for even further delays: “[B]y delaying Stage 2 until 2015, the movement toward improved outcomes that is the main goal of meaningful use would be put off by a full year….” Exactly right. But it is also exactly right that the Stage 2 implementation delay from 2013 until 2014 already put off those “improved outcomes” “by a full year.” In fact, the true delay is closer to two years, since the new 90-day reporting period for 2014 effectively pushes the real Stage 2 implementation deadline to the end of 2014. Glancing at the calendar, the current 2016 deadline for Stage 3 looks significantly softer…and those “improved outcomes” march steadily into the distance.

Unfortunately, because of their own vendor experience, many care providers have bought into the notion that delay is necessary and inevitable. Software-based EHRs are burdened by the inherent limitations of a model that simply cannot keep up with the pace of electronic health record innovation that our health care system needs. It is no wonder that care providers stuck with a software-based EHR perceive a need to slow down.

So what does the delay really mean for providers? It means they have some more time…but not so much as they might think. After all, Medicare payment adjustment penalties are coming in 2015—but they key off of 2014 performance. With innovative, forward-thinking cloud-based EHRs ready, willing, and able to take them through Stages 1 and 2 well in advance of the new implementation deadline, providers are well advised to look to the cloud.

Can we talk?

Industry foot-dragging can also be seen in the final patient engagement and interoperability provisions. Whether the issue is secure communication between providers and patients or between providers using different EHRs, too many stakeholders are answering the question “Can we talk?” with “Not yet, try me later.”

Providers and vendors alike protest that the Stage 2 “View-Download-Transmit” requirement unreasonably tethers providers to patient behaviors that they cannot directly control. Control may be lacking, but that misses the point. An EHR that provides genuinely user-friendly and useful patient access will not have any problem attracting users, with no compulsion required.

In the same vein, many reactions to the final rule’s diluted interoperability standard (only one successful transmission to another EHR or a dummy CMS recipient) protest that it is still too aggressive. We are pleased to see firm interoperability provisions in the final rule, and even more pleased that National Coordinator Farzad Mostashari has concentrated so much post-rule commentary on the topic. We have long pressed, however, for a clear distinction between mere interoperability and actual interoperation. The final rule steps back a bit from the latter, settling on the relatively weak requirement of a single successful out-of-proprietary-network transmission—and still some stakeholders are balking. Stricter interoperation requirements are promised in Stage 3. We hope that promise sticks.

So what do we really think?

What we see in the final Stage 2 rules, ultimately, is yet more evidence of increasing bifurcation (and polarization) in the EHR universe.

On one side are the innovators, with their heads in the cloud (so to speak). Nimble and adaptable, cloud-based EHRs can react quickly to new government standards and transfer adaptations to their providers quickly and all at once. From them arises the chorus: “Raise standards higher–we can reach them. Make deadlines tighter–we can meet them.”

On the other side of the divide sit the laggards, tethered to a software-based model developed when “you’ve got mail!” felt deliciously cutting-edge, hanging on to market share by slowing progress. Rigid and change-averse, these are the EHR vendors for whom the term “software development/implementation/adoption cycle” still holds meaning and drives business strategy. Their chorus assumes the character of a dirge: “Unachievable! Unrealistic! Slow down!”

To be clear, none of this is a criticism of ONC or CMS. There is no way for the Meaningful Use implementation timeline to fully accommodate both innovators and laggards, and a choice to leave the laggards behind would mean also abandoning the providers who still rely on them, along with a whole lot of patients. Nobody wants that. Let’s just not allow the false “too fast/unrealistic/unachievable” narrative to obscure the fact that Stage 2 is entirely achievable, with a forward-thinking approach. As we’ve said before, we believe that results matter—in fact, we’ve staked our reputation and our success on exactly that proposition. Eighty-five percent of our eligible providers have successfully attested to Stage 1 Meaningful Use, a rate that far exceeds the average. And the Stage 1 standards that were carried over to Stage 2 and toughened? Many of our clients already meet them. We are confident that we can help our clients meet the Stage 2 standards—because of our record of success in helping them meet the Stage 1 standards—and collect the significant government incentives awarded for that achievement.

More importantly, we know that, while CMS incentives for Meaningful Use are important and useful, they aren’t the whole ballgame. The true “meaningful use” of a robust, cloud-based EHR generates its own financial incentives: increased productivity, increased revenue, and more time providing care to patients. Realizing these self-generated incentives both increases profitability and quality of practice life—while simultaneously improving the entire health care system.

To learn more, register for our Sept. 19 webinar on Meaningful Use Stage 2 requirements.

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