Vendor readiness
For providers to achieve meaningful use, they must use an EHR certified by an ONC-authorized testing body. Vendors have had to scramble to bring their products up to speed for Stage 2 ever since the federal government finalized the current round of meaningful use standards in September 2012.

[See also: Clinical quality reporting stymies EHRs.]

Only after the products they use gain certification to the new 2014 standards can healthcare providers begin measuring and attesting to Stage 2 meaningful use. But hundreds or even thousands of complete EHRs and EHR modules certified for Stage 1 have not been upgraded to Stage 2 standards (see sidebar), potentially leaving customers in the uncomfortable position of having to change vendors in midstream.

CMS does exempt providers from certain provisions based on "hardship." There have been some unconfirmed rumors that CMS is considering exempting customers of vendors that do not get certified for Stage 2.
EHR usability

One new twist to certification is that the designated testing bodies now must evaluate EHRs for usability, but they do so based on some rather vague instructions.

Usability certification for meaningful use really isn't a test the way the rest of the certification process is, according to Bennett Lauber, chief experience officer of The Usability People, a Fairfax, Va.-based firm that consults on improving user experiences with technology and offers usability testing services.

"(Testers) go out and observe users, and report back to the certifiers," Lauber reports. There seem to be different sets of evaluation criteria because ONC has not really defined usability yet, he adds.

"There are questions and confusion among vendors about what the usability test is," Lauber says. "(Vendors) think they can just do it themselves," and some want to in order to save money.

"There's some education that needs to be done for the vendors," he says. Vendors: "They're just as confused, too."

Lauber suspects that the usability part could lead to a lot of vendors dropping out of meaningful use, creating problems for customers who might get left in the lurch.

Worse, according to Alexandr Romanychev, CEO of WCH Service Bureau, Brooklyn, N.Y., a medical billing company that recently launched an ambulatory EHR with the help of The Usability People, some physicians would rather take the Medicare penalties starting in 2015 than wrestle with a difficult-to-use EHR. Romanychev says some vendors have built user bases not by delivering good products, but by undertaking successful marketing efforts, a point that is hard to argue.

"The major issue is the features of the software," Romanychev says. He says physicians often choose EHRs based on price, which is why some free products have become popular, even if the EHRs are not flexible enough to meet their particular needs. "They take it, then they complain," Romanychev says.

"Doctors don't know how to use it, so training is pricey," Romanychev adds. Physicians also complain about how much time it takes to document patient encounters.

Interoperability
Interoperability – more specifically, lack thereof – is the source of a lot of headaches, too. "We don't know which doctor has which system" when trying to receive information from referring physicians, according to Romanychev. "I have to call doctor No. 2 and find out what program they use."

Stage 2 is supposed to address interoperability, but problems continue to linger.

A particular sticking point is electronic interoperability with laboratories. The Stage 2 rules require EHRs to be capable of accepting coded lab data. "But there's nothing compelling laboratories to put lab reports in the correct format," notes Todd Rothenhaus, MD, CMO of EHR vendor athenahealth, based in Watertown, Mass. This leads to more typing for providers to meet the Stage 2 requirement that they incorporate structured lab results for 50 percent of patients.

The cost of interface development also is high. Rothenhaus says that "a fairly significant number of labs," particularly independent ones, still do not follow the Logical Observation Identifiers Names and Codes – also referred to as LOINC –standard for transmission of results.