Last September, CMS was seriously worried about how many electronic health record vendors would get their products certified under the 2014 Edition of the government's certification criteria before the launch of meaningful use Stage 2 in January. CMS had a solid reason for its concern: As a report released by the National Center for Health Statistics showed, in the first half of 2013, only 13% of physicians both intended to participate in the EHR incentive program and had systems capable of supporting 14 of the 17 Stage 2 core objectives for meaningful use.
The situation has changed significantly since then, however. According to statistics recently issued by the Office of the National Coordinator for Health IT, 86% of eligible hospitals that attested in meaningful use Stage 1 had a primary vendor offering a 2014 Edition product that met ONC's base EHR definition as of Dec. 31, 2013. Seventy percent of eligible professionals fell into the same category, including 80% of surgeons, 81% of primary care doctors and 72% of medical specialists.
While that still leaves a lot of physicians out, health IT consultants do not consider the availability of 2014-certified EHRs to be a significant barrier for most providers who plan to attest to meaningful use Stage 2.
Mark Anderson, a consultant based in Montgomery, Texas, noted that 15 of the 20 vendors that together have a 90% share of the ambulatory EHR market already boast certified products. Both he and Rosemarie Nelson, a consultant in Syracuse, N.Y., said that meeting the Stage 2 requirements will be much harder for most doctors than obtaining or upgrading to a certified EHR.
Nevertheless, important questions remain about how difficult the transition will be and what physicians should do if their vendor does not get their EHR 2014-certified.
To start with, Anderson pointed out, just because your vendor has a certified EHR does not mean that your own product will be upgraded. The major companies are certifying only one or two of their ambulatory and inpatient EHRs, and most certified ambulatory products are oriented to medium-sized and large practices. In fact, he noted, Allscripts sunsetted its MyWay EHR for small practices, and McKesson is no longer marketing its small-group products directly, but instead is letting value-added resellers do that. "It's all about the 200-doctor owned practice of the hospital," he said.
Nelson agreed that vendors are narrowing the range of their certified products and are dropping certain EHRs entirely. But she does not think small practices will necessarily face a dearth of good choices. For one thing, she noted, even with Allscripts having dropped MyWay, its Professional EHR "will work just fine in a small practice." Some major vendors are providing "shrink-wrapped" versions of their certified EHRs that require relatively little setup and configuration, she added.
She also said that some of the newer cloud-based EHRs have all of the required features and could be good solutions for small practices. Examples of such EHRs include 2014-certified products from athenahealth, CareCloud and Practice Fusion.
However, if a hospital or a physician practice has to replace its current EHR to get a certified version, that could present major challenges, Nelson observed. "Even conversions within a vendor's product suite aren't easy."
One reason, she noted, is that when they switch or upgrade to a new EHR, physicians and hospitals may lose some of the customized features that they added to facilitate workflow and documentation, such as customized templates. In one practice that lost its customized templates as the result of an EHR upgrade, seven of 19 providers hadn't recovered their former productivity after six months, she said.
Another challenge is getting vendors to upgrade their customers in a timely manner. That's not usually a big deal with a cloud-based product, because when the vendor flips the switch, everyone is upgraded. But vendors have to make site visits to providers who have client/server-based EHRs to install a new version. Both kinds of EHRs also require retraining of staff, which can be onsite or Web-based.
Anderson said some major vendors are getting backed up on upgrades. He cited one NextGen client who told him the practice could not get on its vendor's schedule for upgrading and training until August. Nelson, on the other hand, has not seen any delays in upgrades of her clients that use NextGen.
Michael Barr, senior vice president of the American College of Physicians, said the association is concerned that small practices will be "at the tail end of upgrades. Let's say they're a rural or a small practice downstream from the larger groups: If I'm a vendor, I'm going to try to get to as many people on my product ASAP. So the small practices might get taken care of down the road."
This could be harmful to physicians who hope to attest to Stage 2 this year, he said, because they have to report for 90 days. That means they must have their upgraded EHR implemented and must be up to speed on it before the beginning of the year's last quarter. Physicians who want to attest to Stage 1 must also have a 2014-certified EHR and must report for 90 days before Oct. 1, he said. Otherwise, they will see a 1% Medicare pay cut next year. Anybody who attested earlier but does not attest in 2014 will lose 1% of his or her Medicare reimbursement in 2016.
Complicating matters further, vendors are also rewriting their EHR software to accommodate the ICD-10 diagnostic code set, which must be used on claims forms starting Oct. 1. Because ICD-10 has far more codes than ICD-9, documentation of patient encounters is more complex. EHR vendors are providing new templates for visit notes, usually in tandem with the meaningful use Stage 2 upgrades, the consultants said.
Fight or Switch?
The vendors that have had their products 2014-certified and that represent the bulk of the market are relatively few in number. Hundreds of small vendors share the rest of the market. Most of them "are really going to struggle" to keep up with the government's requirements, Anderson said.
So the 30% of physicians and 14% of hospitals that do not currently have access to a 2014-certified base EHR may have to decide whether to stay with their vendor or switch to another firm's product.
According to a Black Book survey last year, 17% of physicians who had EHRs were considering a switch to another system. Based on what Barr has heard, he thinks the percentage might be as high as 20% to 25%. But a small survey that ACP co-sponsored did not indicate that most doctors who planned to switch were motivated by the need to show meaningful use. Instead, they were changing EHRs either because their practice had been acquired or because of usability problems, Barr said.
"Usability is a big issue for practices," he noted. "So if they get to the point where their EHR is not functioning for them and getting in the way of patient care, they have to make that business decision."
If a practice has not already installed a new EHR and its current one is not certified, he said, its physicians are unlikely to be ready to attest to meaningful use this year. In any case, he added, if they have already attested for the past two years, it may not be worthwhile to invest in a new EHR and go through all the pain of conversion to avoid a penalty later.
Anderson, who attributed nearly all EHR switching to poor usability or implementation, said it does not make sense for physicians to replace a non-certified EHR if they are relatively satisfied with it. They can get only $8,000 per provider for attesting to Stage 2 this year, and that is not enough to purchase a new EHR. Moreover, he noted, they now have an additional year to attest, since CMS delayed the deadline to the end of 2016.