Proposed CMS Rule Passes Providing Flexibility To Providers Attesting To Meaningful Use For 2014

Participants of the EHR Incentive Program whom have been struggling to deploy new software in order to meet requirements for both Stage 1 and Stage 2 that went into effect in 2014 may be able to breathe a big sigh of relief!

ehr incentive program logo

BACKGROUND: Because of the late release of the requirements for Stage 2, the changes made to Stage 1, and the mandate that all EHR vendors obtain 2014 Certification; the actual deployment 2014 Editions of Certified Electronic Health Record Technology (CEHRT) has been fraught with challenges. Numerous different parties voiced the following concerns to The Centers for Medicare and Medicaid Services (CMS):

  • Vendors were not given enough time to make the required coding changes and certify
  • The certification case load created a backlog of EHR products that were certified later than anticipated
  • Delays in the availability of 2014 CEHRT Editions shortened the time available to providers to implement upgrades, which includes not just the availability of the software but the time necessary to configure changes for patient safety, staff training, testing and workflow revisions in order to be prepared to demonstrate meaningful use.
  • Even when a certified version became “available” due to the high number of users needing to upgrade (Over 350,000 providers) many vendors reported a backlog of several months before providers could be scheduled for the upgrade.
  • Providers that upgrade to the 2014 CEHRT reported that they were still required to install software patches or make workflow changes that hindered their ability to fully implement the product.

In response to this feedback, CMS determined that it might be necessary to grant more flexibility to providers whom were experiencing difficulty implementing 2014 CEHRTs due to the product availability; therefore on May 20, 2014 they released a proposed rule that would make changes to the EHR Incentive Program for 2014 only. The changes would allow providers options to attest for the 2014 reporting period using 2011 CEHRT, 2014 CEHRT, or a combination of both; as well as provide flexibility for users whom were scheduled to attest to meaningful use for Stage 2 to report under Stage 1 (2013 requirements). The proposal did not include any changes to requirements for the 2015 reporting period; providers would still be expected to use 2014 CEHRT for the entire calendar year in 2015.

FINAL RULE RELEASED:

Due to the overwhelming response in support of the proposed changes, CMS released a final rule on August 29, 2014 that will allow providers more flexibility for the 2014 EHR Incentive reporting period.  The rule also extends Stage 2 through 2016 and pushes back Stage 3 till 2017.

Updated Meaningful Use Timeline by First Payment Year

updated meaningful use timline 2014.09.02 from CMS

*3-month quarter EHR reporting period for Medicare and continuous 90-day EHR reporting period (or 3 months at state option) for Medicaid EPs. All providers in their first year in 2014 use any continuous 90-day EHR reporting period.

NEW CEHRT OPTIONS FOR 2014

Providers that are in their first year of participation in the Medicaid EHR Incentive Program who adopt, implement or upgrade CEHRT in 2014 will be required to be on the 2014 CEHRT edition.  All other providers can use the following chart to determine which options are available to them for their 2014 reporting period:

CEHRT SYSTEMS AVAILABLE FOR USE IN 2014

CEHRT systems available for 2014 per CMS 2014.09.02

CMS Resource: 2014 CEHRT Rule Quick Guide – this guide provides corresponding resources based on the option a provider chooses to participate in the EHR Incentive Programs in 2014.

 WHO IS ELIGIBLE TO USE THE CEHRT OPTIONS?

Since reporting options are only available to providers that could not fully implement 2014 Edition CEHRTs due to delays in 2014 Edition CEHRT availability, we thought it would be useful to include some of the public comments concerning this caveat and the official response from CMS:
(Quotes taken from documentation provided by the Federal Register)

Public Comment CMS Response
Precise definition of “not fully implemented” and “2014 availability delays” not sufficiently clear, could encompass endless scenarios, can providers retain the discretion to determine what these terms mean and if not who would ultimately decide? Agreed that some clarification was needed. While some examples were provided it would be impossible to give examples of every possible scenario where inability to fully implement 2014 Edition CEHRT.“Inability to fully implement 2014 CEHRT” intentionally provides the broadest application. Examples of what does not constitute inability are given, and CMS believes that beginning with what is not permissible, rather than what is, represents a far smaller set of circumstances that will both quell providers’ concerns about audits and provide additional parameters on the user of the CEHRT options generally.“2014 availability delays” must be attributable to the issues related to software development, certification, implementation, testing, or release of the product by the HER vendor which affected 2014 CEHRT availability, which then results in the inability for a provider to fully implement 2014 Edition CEHRT. CMS did not intend to allow reasons such as a provider waiting too long to purchase the software, or lack of staff or resources to constitute a “Delay” for purposes of using one of the proposed CEHRT options.
Confusion over whether providers could still attest using 2011 CEHRT options when they have 2014 CEHRT available but could not train personnel or establish new workflow because of late installation The basis for using one of the CEHRT options stems from a problem with first getting the software installed because of EHR vendor delays, and then fully implementing (including training, workflows, and related activities) 2014 Edition CEHRT in time for a full EHR reporting period in 2014. We note that being able to implement 2014 Edition CEHRT for a part of the reporting period is not considered full implementation of 2014 Edition CHERT. Providers who are only able to implement 2014 Edition CEHRT for part of a reporting period would be permitted to use the CEHRT options in this rule.
After the install of 2014 CEHRT, is there a set standard for what would be considered an adequate amount of time to complete all of the transition process (training, workflow, validation of reporting) Several commenters wanted us to specify cutoff dates for training or workflows where we would find it suitable to allow using the CEHRT options. However, such limits would be impossible for us to adequately capture. Because the number and types of providers involved with the EHR Incentive Program vary greatly, we cannot simply state a hard date or exact time because a large hospital chain would possess different time and workflow requirements, for example, than a single EP. However, we can clarify that in order to use one of the options for the use of CEHRT, the provider must not have had enough time to fully implement 2014 Edition CEHRT, including training of staff, perform system testing, and establishing revised workflows in order to report for a full EHR reporting period. If a large hospital, for example, had their CEHRT installed in August, we expect that this hospital would not have enough time to be able to report for an EHR reporting period in 2014 because the hospital would not be able to train staff or establish the necessary changes in workflow. However, if a hospital had 2014 Edition CEHRT installed in January 2014 and decided to wait until August 2014 to begin training, testing and workflow activities, for example, then this rationale would not be sufficient to establish that the provider could not fully implement 2014 Edition CEHRT due to a delay in 2014 Edition CEHRT availability, because the delay was on the part of the hospital.
Is cost to upgrade and/or financial hardship a valid reason for using 2011 CEHRT options? Providers that do not fully implement 2014 CEHRT due to financial issues, such as the cost 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. Although we understand that cost is a factor for health providers, as it is with any other business, we proposed the options for CEHRT to address delays in the availability of 2014 Edition CEHRT, and not the costs associated with it. Providers are advised to apply for hardship exceptions under these circumstances.
Could staff turnover or other internal changes be cause for using 2011 CEHRT options? 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.
Could problems associated with actual objectives under stage 1 or stage 2 be considered as a suitable reason for using the CEHRT options? (Example if a vendor only released capability for the lab result measure in June and the provider is still waiting for the upgrade to report the measure.) An availability delay is not based solely on whether the software is certified and then installed or not, as many commenters questioned. 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. We recognize these issues take time to resolve, and the overall delay in 2014 Edition CEHRT availability may have constrained that time for many providers. 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. We stress that this does not include, as explained earlier, circumstances where the software functions properly but the provider cannot meet one or more requirements of the measure or the increased thresholds on measures common to both stages. The basis for using one of the CEHRT options stems from a problem with first getting the software installed because of EHR vendor delays, and then fully implementing (including training, workflows, and related activities) 2014 Edition CEHRT in time for a full EHR reporting period in 2014. We note that being able to implement 2014 Edition CEHRT for a part of the reporting period is not considered full implementation of 2014 Edition CHERT. Providers who are only able to implement 2014 Edition CEHRT for part of a reporting period would be permitted to use the CEHRT options in this rule.
Concern over attesting for Stage 2 because of lack of 2014 Edition CEHRT availability among other providers would make it impossible to meet the requirement to send electronic summary of care records for more than 10 percent of transitions of care as many recipients would not yet have the 2014 CEHRT functionality required to receive the electronic document. Request to attest to Stage 1 objectives when these circumstances exist. 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.
Concern over inability to meet other measures that require specific use of 2014 CEHRT and whether or not these issues such as direct messaging, portal non-use by patients, mapping problems, or other similar measure issues would be considered an inability to fully implement 2014 CEHRT. CMS 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. We do not find that an inability to meet one or more measures, as in the examples cited previously (inability to meet certain thresholds, objection to Stage 2 measures generally, and concerns with measures believed to be outside of provider’s control-such as inability to obtain a beneficiary’s email address), fits within the rationale we proposed for using one of the CEHRT options. Rather, overall concerns and comments requesting changes or exemptions to one or more of the Stage 2 measures and objectives fall outside the scope of this rule, and will not be discussed with any further detail here. Accordingly, for the reasons stated previously, those providers who have fully implemented 2014 Edition CEHRT and cannot meet one or more measures for reasons unrelated to the inability to fully implement 2014 Edition CEHRT due to delays in the product availability cannot use the options for the use of CEHRT and must attest to their stage of meaningful use using 2014 Edition CEHRT as originally intended.
If a provider had no issues with 2014 CEHRT availability could they still be allowed to use the CEHRT options? CMS does 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.We again stress that the proposed rule was intended to allow options for providers that were unable to fully implement 2014 Edition CEHRT for an EHR reporting period in 2014 due to issues relating to 2014 Edition CEHRT availability delays. Therefore, we will not remove the requirement that a provider’s inability to fully implement 2014 Edition CEHRT was based on issues related to 2014 Edition CEHRT availability delays, because this requirement comprises the primary reason for the proposed rule.

 

ARE YOU ON 2014 CEHRT?

Medisoft Clinical and LytecMD users can determine whether they are on a 2014 certified version of the product by opening Medisoft Clinical or LytecMD, going to the Help Menu and selecting “About Medisoft Clinical” or “About LytecMD.” A window will open displaying the Product Version.

  • Version 11 is the 2014 Certified Version. This version has capability of reporting 2014 Stage 1 Objectives and Measures, 2014 Stage 2 Objectives and Measures, and 2014 Clinical Quality Measures (CQMs).
  • Version 9.5.2 is the 2011 certified version.  This version only has the capability of reporting 2013 Stage 1 Objectives and Measures, and 2013 CQMs.

WHAT SHOULD PROVIDERS BE DOING NOW?

  1. SCHEDULE AN UPGRADE IF YOU HAVE NOT DONE SO ALREADY
    The 2014 CEHRT versions of Medisoft Clinical, LytecMD are available NOW! All Medisoft Clinical and LytecMD users that e-prescribe should already be moving towards implementing the 2014 Certified versions of these products prior to October 1, 2014 in order to avoid eRX functionality from being disabled. (Only the current versions of the products accommodate required changes to eRX)
  2. COMPLETE A MEANINGFUL USE ASSESSMENT
    Given that the last available reporting period for 2014 is October 1-December 31 there may still be time to implement 2014 CEHRT and achieve meaningful use under 2014 requirements. Providers should review the requirements for the Stage of meaningful use they are scheduled to attest under this year. Consider all of the add-on products, setup and configuration for both Stage 2 and Stage 1 that must be completed in order to meet 2014 requirements and asses whether or not your practice has sufficient time to implement changes prior to October 1. AZCOMP is available to assist you with a thorough Meaningful Use Assessment that will provide you detailed documentation on required configuration, training and workflow changes that are specific to your practice, along with an estimate of hours that would be involved to make the changes in order to meet meaningful use. This documentation may prove to be invaluable in showing evidence of both engaging the vendor and feasibility of fully implementing 2014 CEHRT.
  3. DETERMINE WHETHER YOU QUALIFY TO USE CEHRT OPTIONS
    If there are reasons that would hinder you from achieving meaningful use for the Stage you are scheduled for on the 2014 CEHRT,  using the guidelines from CMS included above, you should then determine whether or not the reasons would qualify you to attest under one of the CEHRT options.
  4. SELECT THE REPORTING OPTION FOR YOU CICUMSTANCE
    If you determine that you qualify to use CEHRT options, you should then select which option would be most appropriate for your 2014 reporting period.

CEHRT Interactive Decision Tool Flexibility flow chart

To see your options you can use the CEHRT Interactive Decision Tool  provided by CMS that allows providers to answer a few questions about their current stage of meaningful use and Edition of EHR certification, and the tool displays the corresponding 2014 options.

If you are unsure of which Stage of Meaningful use you are scheduled to meet for the 2014 reporting period you can use the EHR Participation Timeline Calculator which will ask you to enter the program you are participating in (Medicare vs Medicaid) and the year you first participated, when the results display simply click on 2014 to see which Stage you are scheduled for this year.

QUESTIONS EACH PROVIDER SHOULD ANSWER:

  1. Which software version will I be using during my reporting period? (2011 CEHRT/2014 CEHRT or both)
  2. Will I be reporting Objectives and Measures for: 2013 Stage 1,2014 Stage 1, or Stage 2
  3. Which reporting period they will I use for my 2014 attestation?
    1. If this is your first year in the program you can attest for any continuous 90 day period, if you are trying to avoid the Medicare penalty for 2015 you must attest by October 1, 2014.
    2. If you have you have attested to meaningful use in prior years you can select any 3 month quarter. (Jan-March, April-June, July-Sept, Oct-Dec)
  4. Do I have supporting documentation for the selections made above? Things to consider:
    1. Providers must report produced by the CEHRT that provide the numbers that are used to attest. Providers are advised to keep copies of the reports as supporting documentation in case of an audit. (Documentation should be retained for six years post-attestation.)
    2. Not all objectives require a numerator and denominator in order to attest. These objectives simply require the provider to answer yes or no to having met the requirements for the measure. CMS has advised providers to keep supporting documentation, including screen shots taken during the reporting period as evidence that the functionality was enabled in case of an audit. (Measures were screen shots are recommended include Drug and Allergy interaction checks enabled, Formularies enabled, implementation of Clinical Decision Support Rules, submit data to immunization registries, or submit syndromic surveillance data)
    3. Providers that plan to attest to have generated lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach (Menu Objective 4 in Stage 1, and Core Objective 11 in Stage 2) should also retain a copy of report dated during the reporting period in case of an audit.
    4. All providers are required to complete a security risk analysis ever year and documentation of the analysis should be retained in case of an audit. The security risk analysis can be completed prior to or during the reporting period but not after. For example, if for their 2014 attestation a provider chooses the second quarter as their reporting period (May-June) the security risk analysis can be completed at any time between January 1- June 30, 2014. Regardless of when the provider actually submits their attestation, if the security risk analysis was not completed before or during the selected reporting period the provider would not qualify as a meaningful user.

ENSURE THAT YOU ARE READY FOR 2015!

Keep in mind that there have been no changes to 2015 requirements. All existing participants, regardless of their Stage still be required to attest for the entire calendar year using 2014 CEHRT, which means providers must plan to fully implement both the software and changes necessary for the Stage they are in prior to January 1, 2015. Make plans now to ensure you are ready for both 2014 and 2015!

Disclaimer: AZCOMP Technologies, Inc, (AZCOMP) is providing this material as an informational reference for eligible professionals. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of posting, the Medicare/Medicaid programs are constantly changing, and it is the sole responsibility of each provider to remain abreast of  program requirements by consulting the authorities and documentation found directly at http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html