Let’s get some numbers laid out first, so we can have an informed discussion.
- According to CMS, back in 2011, the first year of Meaningful Use, approximately 60,000 physicians attested to Meaningful Use of a certified EHR and 50,000 more attested to buying or upgrading to one. That’s at least 110,000 doctors that purchased a certified EHR in 2011, and probably more.
- By December 2013, 213,000 unique physicians attested to Meaningful Use in the Medicare program, over 20,000 for the first time in 2013, and most likely a bunch more newbies will be added in January and February of 2014. For Medicaid, 100,000 doctors attested to something so far.
- If everybody continues to participate in the program, we are looking at upwards of 350,000 physicians, not counting new ones in 2014, that will be needing an upgrade to a 2014 certified EHR, which is the only allowed EHR edition in 2014, whether one is attesting to Meaningful Use Stage 1 or Stage 2.
- The number of 2014 certified ambulatory EHRs is approximately the same now as the number of certified EHRs was in January 2011. While the supply is the same, the demand should be 3 times higher.
If this is not your absolutely first year of Meaningful Use, all attestation periods are tied to calendar quarters in 2014, so you can either start on January 1st, April 1st, July 1st, or October 1st. You cannot just run reports until you find a “good” 90 days period. If one of those four periods is not good enough, that’s too bad, you’re out for the year, and since this is a new EHR version, chances are some unexpected “glitches” may occur. In the past, people devised several “workarounds” to improve on Meaningful Use reports prior to attestation. Those workarounds included, retrospective data updates for things like problem lists or demographics, and the perennial favorite of “print to file”, where clinical summaries are sent to a virtual PDF printer to increment the EHR count with minimal deforestation effects. Since attestation periods are fixed now, and since those attesting to Stage 2 are looking at significantly higher thresholds, and some new ones to boot, one should expect a much higher incidence of innovative fixes to workflows.
Another thing to keep in mind is that clinical quality measures (CQM) reported this year, partly for PQRS, may become public. While in the past, the numerator for these measures was irrelevant to attestation success, good performance is very important now, and carelessness with the numbers may very well come back to haunt you in the not too distant future. Fortunately, CMS has increased the pool of CQM sanctioned for reporting, so everybody, including specialists, can pick measures pertinent to their practice. Unfortunately, with the exception of a handful of EHRs, most vendors chose to not certify for all possible measures, so this year, just like in 2011, most physicians will have no choice of CQMs. Keep in mind that the reporting requirements for CQMs in 2014 is the same for all participants (i.e. 9 measures, electronically submitted), regardless of Meaningful Use Stage, except for first year participants, who are exempt from the electronic requirement.
[Note: On 2/1/2014 HIMSS, the EHR vendors association, has posted a remark on the HIStalk blog stating that "CMS is permitting manual attestation on clinical quality measures for meaningful use in 2014, as has been done through 2013, not just for those in their first year". The official CMS website is stating otherwise, but I am not one to dispute the insider information of HIMSS, so expect some changes.]
Speaking of choices, those planning to attest to Stage 2, are allowed to pick 3 measures out of 6 menu choices, two of which are practically impossible to choose, since not many States have the ability to receive electronic data to cancer, or some other registry (other than immunizations), and also because almost all 2014 certified EHRs chose to not certify themselves for these measures. Realistically, there are no menu choices for Stage 2, and we should have probably never expected any, based on recalling that back in 2011 many EHRs were certified for functionality they didn’t really have (e.g. immunizations interfaces in all 50 States).
Another baffling set of numbers comes from this year’s National Ambulatory Medical Care Survey (NAMCS). A joyfully reported 78.4% of physicians in the U.S. have an EHR, and 48.1% have a “basic” one (i.e. an EHR with functionalities that could satisfy basic Meaningful Use requirements), or better. The question that always springs to my mind looking at this graph is what on earth do 30% of doctors have in their practice? Microsoft Office? There is practically nothing you can buy today that does not meet the definition of “basic”, yet the gap between basic EHR and any EHR, shows no signs of narrowing down, which in my mind, makes these survey results questionable at best, but I digress.
The 48.1% of basic EHR users matches very well with the approximately 350,000 physicians that are participating in the Meaningful Use program. The NAMCS also finds that 13.1% of physicians are ready for Meaningful Use Stage 2, which means that practically all physicians that started their Meaningful Use journey in 2011 were using a 2014 certified EHR and were ready to move up the ONC escalator at the time they were surveyed. Considering that the “2013 NAMCS EHR survey was conducted from February through June 2013”, I doubt that very much, seeing that there were no 2014 certified EHRs on the market at that time. Perhaps those optimistic doctors meant that they are confident that they (and their EHR vendors) will be ready when the time comes.
Either way, we are left with over a quarter million doctors who don’t think they are ready for Meaningful Use Stage 2, and perhaps unbeknownst to them, they are also not ready for Meaningful Use Stage 1, which requires this year a brand new, 2014 certified EHR, and another two hundred thousand physicians who think they have an EHR, but really don’t. If 2014 was designed to stress test the $18 billion (so far) Meaningful Use program, odds are the crash will be spectacular. If, on the other hand, the thinking was that as long as the camel is on the move up the escalator, we can happily add bale of straw after bale of straw to its back ad infinitum, we’re in for a bit of a surprise this year.