If healthcare IT leaders weren’t already overwhelmed with priorities and must-do items on their to-do lists, they might well stop to pause at the sheer number of deadlines and other time-sensitive elements to consider under healthcare reform and meaningful use. Both the Affordable Care Act (ACA) and the American Recovery and Reinvestment Act/Health Information Technology for Economic and Clinical Health (HITECH) Act, through its meaningful use process, are imposing federal mandate after federal mandate on hospital organizations and on physicians (and therefore on physician organizations as well, of course) in the next several years; and keeping track of all the deadlines and other time-related elements under both legislative programs will continue to be a source of confusion and frustration for many, going into the foreseeable future.

What’s more, the healthcare reform-related mandates are coming under three main mandatory programs: the value-based purchasing program, the healthcare-acquired conditions reduction program, and the avoidable readmissions reduction program. And of course, as providers move into Stage 2 of the meaningful use process, the requirements become both more numerous and more complex.

And of course, there is the mandatory transition to the ICD-10 coding system as well; a transition whose specific trajectory is somewhat clouded at the moment by the decision of the Department of Health and Human Resources (HHS) to postpone the universally mandatory transition date of Oct. 1, 2013, without immediately announcing the replacement date.

In the midst of all this, Erica Drazen, Sc.D., who this week is retiring as partner in the Waltham, Mass.-based Global Institute for Emerging Healthcare Practices at the Falls Church, Va.-based CSC, last week gave HCI Editor-in-Chief Mark Hagland an industry-exclusive interview, along with industry-exclusive publication rights to two charts she and her colleagues have developed (see Figures 1 and 2 below), which layout in graphical format the broad web of timelines and deadlines under all these programs, for the next couple of years (see image gallery for both figures). Below are excerpts from that interview.

Figure 1 [For higher resolution images of these figures, please check the gallery in the upper left hand corner.]

Figure 2

It was quite a process to put these figures together, wasn’t it?

Yes! It was a huge challenge to find all these dates. And I finally found a document from CMS [the federal Centers for Medicare and Medicaid Services] that talked about physician quality reporting and e-prescribing, together. Most of the time, most of the e-prescribing stuff is presented year by year. And the other thing that’s amazing is how quickly it changes.

You devoted many hours to this; I can only imagine that the average physician in group practice would be totally at sea with all these overlapping deadlines from the various programs.

And imagine the poor solo physician! You can’t find out the consequences of being an e-prescriber and a meaningful user submitting data, except through this one document. And the penalty for not being an e-prescriber and a meaningful user is 2 percent and then 4 percent of revenues, the reimbursement cut: in 2018, the doc penalty is 4 percent of Medicare reimbursement. For hospitals, it’s a percentage of their annual update.

And I had to color-code the years, because look at what happens in 2012 for docs. How could you possibly keep track? It’s very complicated, it’s not easy to figure out, there are lots of nuances to it, and the other thing that a lot of people don’t realize is, the penalties apply to everyone. And some docs are going to participate under Medicaid. But if you apply to the Medicaid program and don’t fulfill your requirements, you will still be penalized under Medicare, even though Medicaid has no penalties. And 30 percent of your population has to be on Medicaid to get the Medicaid incentives. And the Medicaid incentives are bigger. But if you don’t meet the meaningful use requirements under one of the programs, you will still penalized under Medicare.

Do people even know that?

I don’t think so.

What are some key things that hospital people don’t know?

Well, the hospital side is clearer; but one of the things that people may have overlooked is that the last time you can attest to meaningful use and avoid any penalties, if it’s your first year, is by July 1 of 2014. You have to have met the requirements and attested to any stage, by July 1, 2014. It’s not when you need to start, it’s when you need to finish, to avoid penalties in 2015. And if it wasn’t your first year, you had to be a meaningful user throughout 2013, in order to avoid the penalties in 2015.

So there are two ways to avoid penalties—there’s kind of the ordinary way; or, if it’s your first year, everything has to be done by July 1, 2014, to avoid penalties in 2015. And it was always true that the penalties would begin in 2015, but it wasn’t clear what the performance standards would be.

What are the biggest misunderstandings in the industry about all this?

They’re around how to avoid penalties in 2015, and all the requirements you have to meet. The other is that  by October 2013 (for the year 2014), you have to have in place an information system certified for the 2014 requirements, the new requirements that have just been published in draft. And the certification requirements are not tied to stages; they’re tied to dates. So if you started in 2011, you’ll be at Stage 2 in 2013; if not, you’ll still be at Stage 1; but the system has to be certified against the new 2014 requirements, and that starts October 1, 2013.

It’s very hard to keep this straight in one’s mind, isn’t it?

Yes, it is. And remember that the year runs from January to January for doctors, but begins on October 1 of the prior year, for hospitals. So when they think about this idea that they have to have a system certified by 2014—it’s been in the law all along, but since the requirements are new—there are new requirements—and the systems will need to be certified, even if there are no changes in requirements. That says that pretty much every hospital in the country will have to undergo an upgrade of their system.

Remember, you have to be a meaningful user of a certified system. And the vendors have gotten their systems certified (or self-developed products) against Stage 1. But that whole concept of Stage 1 has gone away; now they’re referring to 2011. So if you have a 2011-certified system, that runs through 2013. But starting the next year, you have to have a 2014-certified system that meets all the new requirements and standards and has all the new capabilities. So that means that every hospital will have to have its system certified for those requirements by October 1, 2013, to be a meaningful user. Now, there are exemptions in the requirements. If it’s a future-stage requirement and you’re still in Stage 1, your system doesn’t have to be certified for that, but there are a lot of changes in the core requirements that mean that no matter what you buy has to have a 2014 certification.

The 2011 certification will be no good after 2013; and what’s more, the certification requirements are different enough that even if you’re still in Stage 1, you’ll have to make changes. That means that everybody’s going to have to have a newly upgraded system. And what’s unknown is how vendors will react; they may decide they’ll only update some of the current systems out in the field, to the new certification.

I looked at this initially and said, gee, those requirements aren’t all that different; and these are things that people know how to do, like e-prescribing in the hospital; and maybe the hospital systems don’t have it, but they could develop it. The thing is that I don’t think the amount of engineering and new product development is insurmountable; it’s the implementation part that will just be huge, because of the fact that every single hospital has to have this updated system, if they want to be a meaningful user. And by the way, you can’t have anything certified yet, because the requirements won’t be out until this summer.

Will vendors be challenged to move forward in time?

I think they’ll have problems getting all their customers to a 2014-certified system in time; I do think that will be a major challenge for people. So what if the requirements are out this summer, which they promised? That’s the summer of 2012. They need all these systems in place, in their client base, one year later, implemented. Because the hospitals have to be using them.

How big will that upgrading task be? It’s hard to envision what the sense of scale will be.

I don’t think the upgrading is massive. But small upgrades are a challenge when they’re brought across an entire mass of hospitals that have different tweaks and customizations, and may already be behind in terms of upgrades. And some people may be stuck, in that the system they’re using isn’t going to be upgraded by their vendor to the new 2014 specifications. What do they do? They can self-certify, or buy a new system.

So if you’re a hospital with an outdated version of your vendor’s EHR product, you could be faced with a situation where your vendor is going to abandon the version you  have, and you could be faced with a fully new implementation right now?

Yes. And you don’t want to tell people they’ll need a huge upgrade, too far in advance, because that would be difficult; but I just think that nobody thought about the trouble that would occur with the 2014 system requirements. And it’s not new news; it’s just that we weren’t really paying attention, and people didn’t really understand that the requirements would be changed. And they are going to be changed; for instance, you have to code your new problem list in SNOMED as opposed to in ICD-9. And that will be one of the 2014 requirements. And that affects everyone.

The irony is that the National Library of Medicine is working on a translation between SNOMED and ICD-10, which now won’t be implemented as early as had been expected. And they’ve greatly increased the amount of information that has to be transmitted and that has to be made available for sharing with patients.

So the amount of work that has to be accomplished in a short time is much more remarkable than people realized?

Yes, and everybody thought that giving everyone an extra year to be in Stage 1 would be a solution; but the fact that you have to manage this system certification issue really takes away from that. The other thing is everything below the line on the hospital chart; and who’s paying attention to that? And they really haven’t declared much of anything beyond 2013, except that there will be penalties. Well, 2013, for hospitals, starts in October of this year! So I think we really haven’t had enough discussion about getting everyone who wants to be a meaningful user to get their system prepared in time. Remember, this was supposed to come out in draft form in December, and didn’t.

Also, information exchange at transitions of care used to be a menu requirement, and is now a core requirement. So in Stage 2, you have to exchange information at transitions of care. In Stage 1, you had to test that capability, and test it with someone in a different corporate entity. And in Stage 2, which will start in 2013 for people who started in 2011; and the proposal is that you will have exchange information of your patients, and for 10 percent of your patients, that information exchange with the next provider of care, has to be done electronically. So instead of testing one time, you will actually have to do it 10 percent of the time, under Stage 2. And the proposed rule says it actually has to be with a different vendor product. The fine print is important! I’m actually encouraging people to write in about this. And because of that, many people in a geography have standardized on one vendor product. Where would you exchange in the Northwest? And are you going to pick your PCPs, based on that they have a foreign system? And in many cases, PCPs and specialists are going to have the same system. So the implications of it are bizarre.

And I’m sure that that requirement will be changed, but my whole point is that there are a lot of subtle things in this rule related to the details that have changed, and the standards that have changed, that will engender comments. I think the comments on this particular requirement, for example, will be more. So when will we have the final rule on Stage 2? In August? I certainly don’t think it will be ready in July. So I think people are underestimating the amount of change that will be required. And I think we need to be cautious about the schedule.