It turns out this stuff is really hard, after all. 

About this time last year, we ran an article in these pages titled, "Stage 2 changes may be rude awakening." In it, one hospital IT honcho made the point that, with attestation for meaningful use still off in the distance, most providers were blissfully ignorant of just how difficult the process would be.

Too few people "really, truly grasp the magnitude of some of the changes," compared to Stage 1, he said.

Here we are, more than halfway through 2014, and the numbers are starting to roll in. They're anything but impressive.

On July 8, the Centers for Medicare & Medicaid Services released statistics showing that just 3 percent of eligible hospitals and 1 percent of eligible providers have attested to Stage 2 so far.

Pointing out that these figures represent an exclusive class of organizations that had 2014-certified EHRs in place and ready to go by Jan. 1, Elisabeth Myers policy and outreach lead at CMS' Office of e-Health Standards and Services, argued that it's "dangerous to apply interpretations" to such early returns.

Agree with that or don't, but there's no sugar coating the fact that these numbers are lower than folks at CMS and ONC would prefer to see.

Even as recently as this past February, when the health IT industry was gathered in Orlando for HIMSS14, few suspected the attestation numbers would be this underwhelming.

Hopes dashed

"I was more optimistic," says John Hoyt, executive vice president of HIMSS Analytics.

"We were even doing research at the end of last year, and this past January, in our leadership survey, and we were getting huge numbers of respondents telling us that they were going to attest by the end of 2014," says Jennifer Horowitz, senior director of research at HIMSS Analytics. "For me, it will be very interesting to see what those numbers look like, come the end of the year."

In May, HIMSS released its "2014 Meaningful Use Stage 2 Readiness Assessment," and even that report found that that "the provider community generally seems to have a positive view of their ability to meet the deadline."

Some 71 percent of hospitals expected to attest by the end of 2014, while just over 22 percent said they'd do so in 2015.

Asked whether they're running on "installed 2014 certified EHR product(s)," 75 percent of hospitals said yes; a bit more than 20 percent were "presently completing installation."

But there are sticking points, says Tom Leary, vice president of government relations at HIMSS. And they tend to be the same measures across all providers.

"View/download/transmit and transitions of care are the two most referenced, both anecdotally and in the survey," he says, referring to the 5 percent threshold for patient access to health data and the 10 percent threshold for electronically transmitting summaries of care. (See "Pain threshold," page TK, for a look at one hospital's frustrations handling the two measures.)

The feds have taken note – to some extent.

"We hear from the government that their attempt to fix the 2014 reporting requirement is their attempt to address the challenges providers are having with implementing the upgrades, and then more specifically view/download/transmit and transitions of care," says Leary.

The requirement for electronic clinical quality reporting is another persistent pain point.

"Where they're having trouble is that when they do it electronically, their percentage is lower than if they do it electronically and do chart abstraction," Leary explains. "And some are still in the place where they're not completely comfortable with the standards supporting the quality reporting requirements, and so the product they use, if they do it electronically, it reports a lower (number) and they don't meet the threshold – or they just barely meet it. As opposed to if they do the chart abstraction, they're able to meet the requirements."

"That tells us that their system is not collecting the data that they need to report," says Hoyt. "And if they're not totally automated they can go find it on paper. So that is either a) a vendor issue, or b) an implementation and process redesign issue." 

Vendor 'issues'

Vendor "issues" are another common complaint.

Even as long ago as this past summer, some observers were noticing disquieting trends from providers. In July 2013, MGMA consultant Derek Kosiorek noted that he was concerned with what he was seeing in the field. "The over-reliance on the vendors is stunning," he said. 

Too many practices, he said, were simply "waiting for the vendors to release the product." And too often, as we've seen, that product is slow or late in coming. 

As Frank Irving, editor of Healthcare IT News' sister publication, Medical Practice Insider, reported in May, EHR vendors' failings, especially that they had been slow in releasing the necessary upgrades, and that was having serious real-world consequences for well-meaning providers.

"This year the challenge is the 2014 upgrade," Erin Dormaier, program manager for CFMC, Colorado's Medicare Quality Improvement Organization, told MPI. Specifically, she referred to one "relatively popular" vendor, whose tardiness would effectively preclude first-year attesting providers from meeting the Oct. 1 deadline.

Federal agencies are bending, to an extent. Practices nationwide are filing for hardship extensions with CMS, proving that their attestation has been hamstrung by delays in certified products. 

Quality reporting

But when it comes to CMS and ONC, the current flexibility is about "the extent to which they can do it for 2014," says Leary – when it comes to quality reporting, especially.

"What we're looking at in 2015 is that, from a clinical quality measure perspective, they coordinate with other federal programs," he says. "We just got the HIMSS board of directors to approve a truncated timeline, which would be a new approach for the government – 90-day reporting, as opposed to the full year, for 2015 for anyone who's in year two of Stage 2.

"And also, getting it in sync with (CMS') inpatient prospective payment system, which would allow a little more flexibility around when information is gathered and have the same requirements – submit the same requirements – as opposed to two different programs having separate and equally time- consuming in terms of information gathering, so they sync up the requirements even more thoroughly." 

But, "in terms of what are they going to do in 2014, we're running out of time," he says. "There's not much more they can do for Stage 2 other than what the AHA and AMA have been calling for, in terms of creating some extra flexibility in terms of how close you get to the percentages.

"If you get 23.5 percent, instead of 25, are you still a meaningful user if you've come up (to that point) from 7 percent? (But) our board has not been supportive of that. Because where's the threshold then? Everybody has agreed on the threshold for these percentages, they've known about them. If you get nine out of 10 on this, three out of four on another – suddenly you've just got a big old … something that's more difficult to manage."

Right now, it's looking like Stage 2 itself is too difficult to manage for too many hospitals and practices. With so few attesting so far, can we really expect a significant uptick by the end of this year?

"I would say probably not," says Hoyt. "I would not expect a floodgate. We should have had more momentum early on. That means there are clearly software and process issues. And it takes a long time to solve those. I think we're going to be looking at a significant deficit."