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EMR Stimulus Myth #2: “I have a CCHIT certified EHR so I am good to go for meaningful use”

It is likely that CCHIT will be one of the accredited certification body under the EHR incentive program. HOWEVER, given that there is no formal EHR certification program available from ONC yet, no existing certification, including from CCHIT, means much towards meaningful use.

As I covered in EMR Stimulus Myth #1, even if you implement an ONC certified EHR (when the certification program is finalized), it does not get you to meaningful use. Providers have to meaningfully use the certified EHR and report on defined clinical qualify measures over a set reporting period to meet meaningful use. Given that no EHR today is certified, how should you proceed with EHR purchase decision?

If you are making the decision to buy an EHR now, YOU MUST VETT THE EHR VENDOR prior to purchase so that you minimize the risk of buying the wrong EHR. Vetting should include the assessment of EHR against the current definition of certified EHR from ONC plus the match of EHR to the makeup of your organization. Of course, any promises of future from the vendor should be baked into the contract you are executing with them. EHR needs of a solo or a small practice group is much different than a larger group/clinic/hospital.

People often find real value in getting the assistance of a meaningful use expert for this assessment. The pitfalls avoided make it worth the investment. You don’t want to purchase and implement an EHR and then find out your EHR won’t meet the meaningful use requirements. That would be a depressing realization.

About David:
David Lee is the Principal at eRECORDS, Inc.  David has provided successful healthcare technology, CRM and financial product consultancy for the past two decades and most recently, guiding healthcare organizations to “meaningful use”.   You can reach David at david.lee@eRecords.com or visit www.eRecords.com.

CCHIT has published their comments made on the Interim Final Rule (45 CFR Part 170, RIN 0991-AB58), published in the Federal Register of Jan 13, 2010, “Health Information Technology: Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology.” Or as I like to call it, the EHR Certification criteria.

Here’s 3 paragraphs that kind of describe CCHIT’s broad feedback on the EHR Certification criteria:

Before offering detailed suggestions, the Commission wishes to highlight three overarching concerns with the IFR as written:

• Scope. While “Complete EHR”sounds like a desirable certification, the package of requirements in the IFR may not match the needs and expectations of doctors and hospitals, nor the realities of the marketplace, for EHRs. By including two functions of an administrative/billing system in the scope of EHR certification, ONC may exclude one third or more of the offerings in the current EHR marketplace, while suddenly forcing hundreds of billing products to undergo unnecessary certifications. In other areas, the scope falls short of being complete: for example, an EHR that does not offer competent electronic management of progress notes would be unusable and medico-legally unsound, and an EHR that fails to prominently display patient advance directives in an emergency could compromise patients’ rights at their time of greatest vulnerability.
• Interoperability. The Commission and its expert volunteer panels believe that certain criteria and standards in the IFR represent a step backwards in progress toward EHR interoperability. For example, well-defined standards for receiving electronic laboratory results in the doctor’s office and for exchanging clinical summaries had already been recognized by the Federal government and widely supported by industry – as evidenced by the certification of over 80 EHR products to those standards in 2008. Yet under the IFR, that standard for receiving laboratory results, and the specific implementation guidance for exchanging clinical data, have been dropped. Where one standard was previously recognized for clinical data exchange, the IFR offers two different, incompatible standards. Conversely, other interoperability criteria in the IFR, such as the requirement that EHRs be capable of transmitting biosurveillance data to public health authorities, could immediately increase EHR cost and complexity while benefits remain years away because public health authorities lack standards-compliant infrastructure and systems for receiving that data.
• Functionality. Some of the IFR criteria define required functionalities of an EHR too microscopically, adding unnecessary complexity and creating barriers to innovation. Other criteria are too vague to be reliably verified in a testing process, creating a risk that the expectations of providers, payers, and the public regarding the performance, safety, and benefits of Certified EHRs will not be met. A particular concern surrounds the reporting of quality measures, with the IFR calling for standards and measures that are yet to be defined or that require significant revision to make them computable from EHR-based data.

I’ll be interested to hear people’s comments about CCHIT’s feedback on the HHS EHR Certification Criteria.

I always love when people are interested in doing guest posts on this site. This is going to be the first in a series of blog posts about some of the misinformation that’s out there about the EMR stimulus, certified EHR, and meaningful use. I hope you enjoy!

My name is David Lee and I am a principal of a healthcare technology consulting firm called eRECORDS, Inc. Day in and day out, I talk to independent physicians, practice group owner and community clinics about HITECH Act and “meaningful use”.  My company takes pride in providing accurate and up to date information to the physicians and clinics so that they can make intelligent decisions about meaningful use.

I am continually amazed at the misinformation surrounding meaningful use and the one that scares me more than anything else is ”My EHR vendor told me that if I implement their certified EHR, I will meet the meaningful use requirements and collect EHR incentive payments.”

It is true that a “certified EHR”  is a key component to meeting the requirements of “meaningful use”.  However, a “certified EHR” is not the silver bullet to meaningful use.  Let me share some important facts:

• Fact: Although the definition and requirement of a certified EHR has been released by the ONC, there is no organization recognized or approved by the CMS to certify EHR to meet the requirements of the meaningful use criteria.
• Fact: Even if your organization implements a certified EHR (when certification bodies are appointed and your EHR vendor passes the certification), this does not get you to meaningful use..
• Fact: Meeting meaningful use requirements involve qualified providers meaningfully using a certified EHR and reporting clinical quality measurements.  The key words are “meaningfully using” and “reporting” not simply having a certified EHR.

Don’t be fooled by any vendor claiming that they are certified or promising they will be certified.  Although some EHR vendors are better prepared to meet the certification when available, not a single vendor today is certified for the EHR incentive payment program.  More importantly, you cannot meet the requirements of “meaningful use” by simply implementing a certified EHR. It is vital that you find experts who can provide accurate assessment and plan for “meaningful use”.

This is a continuing series where David will share and hope to clear the myths about HITECH Act and “meaningful use”.

About David:
David Lee is the Principal at eRECORDS, Inc.  David has provided successful healthcare technology, CRM and financial product consultancy for the past two decades and most recently, guiding healthcare organizations to “meaningful use”.   You can reach David at david.lee@eRecords.com or visit www.eRecords.com.

Anyone that works in Healthcare IT knows who John Halamka is and so of course I was interested in his post of his top 10 impressions after HIMSS. It’s an interesting list and I think he does a pretty good job of looking at things from a very high level. Here they are as posted on his blog:

1. Meaningful Use is everywhere. Vendors are promising EHRs, modules, appliances, and services to help clinicians achieve it. I had dinner on Monday night in a small Indian vegetarian restaurant. Sitting next to me were 3 engineers from Bangalore who were arguing about the details of Meaningful Use in between bites of vegetable curry. I could not escape Meaningful Use anywhere!

2. Certification is everywhere. It’s particularly ironic that many vendors claimed their systems were certified, even though the certification NPRM was just released today, making compliance with the new certification process in time for HIMSS impossible.

3. Cloud computing, Software as a Service and ASP models are popular tactics to accelerate EHR rollouts. There are still lingering concerns about how to ensure privacy in a cloud environment.

4. Several firms such as Intersystems, Axolotol, and Medicity are offering HIE platforms that include many of the standards noted in the IFR. The marketplace for HIE products is just emerging and it’s hard to predict who will become the market leader.

5. The Continuity of Care Document is gaining traction. I found many vendors supporting CCD exports from their EHRs. A company called M*Modal , has developed natural language processing technology that captures dictated content in its original context (ontology-driven
rules) as a CDA document.

6. Consultants abound. It’s clear that Regional Extension Centers and Health Information Exchanges will require expertise and staffing from professional firms. They all had large booths at HIMSS.

7. 30,000 people attended, including 10,000 I did not recognize (just kidding). It’s clear to me that many IT professionals, even those with limited healthcare domain expertise, attended HIMSS to better understand how they could participate in the euphoria of HITECH stimulus dollars.

8. Self service kiosks for patient identification and self-registration are now mainstream. Just as we print our airline boarding passes, we can now use credit cards or biometrics to check into ambulatory care appointments and automatically settle all co-pay balances.

9. Image exchange in the cloud is being offered by several vendors. As I mentioned in Monday’s blog, Symantec announced an appliance for small clinician offices that cloud enables all imaging modalities using a facebook-like social networking invitation to share/view images.

10. PHRs and patient engagement are becoming more mainstream. Google and Microsoft continue to innovate in the non-tethered PHR marketplace.

I’ve written a number of times about Drummond Group becoming an EHR certification organization in order to obtain the EMR stimulus money. Well, the Drummond Group has created a blog to keep you informed about theri partcipation in EHR testing/certification.

Here’s the most important part of their first post on their blog:

It appears Booz Allen Hamilton (BAH) will be developing both the testing certification documents as well as the framework for authorizing certifying body for EHR certification.

Once that final piece of the puzzle is revealed, we can begin making more detailed plans for EHR certification. Until then, we believe attempting EHR certification is, at best, premature and, at worst, potentially a significant waste of time and money for ourselves, the certifying vendors and the adopting physicians and hospitals.

However, this waiting period does not mean we are idle. We will be making regular posts here on various EHR certification topics. Since many of you are not familiar with us, we will share a bit more about DGI and our qualifications to be an authorized HHS certifying body for EHR. We have a great deal of experience in system-to-system interoperability and are excited to bring that knowledge to the EHR community. Since we are getting so many emails from vendors interested in EHR certification, we will talk about some of the concerns we are hearing and thoughts on how to best address them.

This is exactly why you should want to be certified by Drummond Group and not CCHIT. I agree with them saying, “attempting EHR certification is, at best, premature and, at worst, potentially a significant waste of time and money for ourselves, the certifying vendors and the adopting physicians and hospitals.“

CCHIT’s Mark Leavitt has published his analysis of the $400,000 contract that NIST awared to Booz Allen Hamilton to develop a framework for electronic health record certification (see certified EHR).

Honestly, it seems that Mark’s as confused as everyone about this whole process. This is an interesting development since I would have thought that CCHIT would have had a close relationship with HHS, ONC, NIST, CMS, etc. The fact that CCHIT and Mark Leavitt are kind of left in the dark and full of lots of questions is not a good sign for CCHIT and fans of CCHIT. It is a good sign for those who don’t care for CCHIT.

A number of people are starting to write about the meaningful use criteria. I’ll plan on highlighting a number of the comments happening around the web about meaningful use here on EMR and EHR. The first up is the always interesting HIStalk’s thoughts (see bullet points below) on the recently released meaningful use interim final rule and a link to HISTalk’s excel file listing the provider requirements for meaningful use (a good place to start for doctors).

• I’m trying to figure out who the big winners will be if these criteria are approved. Consultants for sure. Companies like RelayHealth that provide eligibility, claims, and information exchange services. Companies that can perform a security analysis. Vendors that offer a usable medication reconciliation function. Vendors with patient portals. Companies that can help put vital signs information directly into the EMR.
• Losers: EMR vendors already strapped to pay for CCHIT certification who now have to cough up another million or two to meet the additional requirements. That’s another blow to small and innovative vendors who aren’t raking in the cash, meaning the market tilts even more in favor of the older, bigger ones whose sales were so limited that the government decided to intervene in the free market in the first place. Market consolidation is probably good, but I expect the development agenda will now be even more driven by Uncle Sam, not users (especially since the HITECH sales window is small, so even sales-driven innovation may dry up once everybody has chosen their dance partner).
• Lots of folks, me included, expected the criteria to be a slam dunk for moderately tech-savvy hospitals and practices. Not so: considering the small percentages of them using CPOE and e-prescribing, the minority that can provide electronic copies of information to patients, and the small number of practices that can provide patients with fast access their online health information, the these are stretch goals. I bet those requirements will be dialed back in the final version for that reason.
• Good luck with providing the denominator number for the reimbursement measures. You will need to know the total number of prescriptions generated, the number of orders issued, and the number of episodes in which medication reconciliation should have been performed. The document indicates an estimated time to generate the denominator at one hour using the EMR’s capabilities, which is surely a mistake since the EMR doesn’t help you count paper orders.
• The CPOE requirement is generous to hospitals, which have been screwing around since the 1980s trying to get doctors to use CPOE with dismal results. They are required to hit only 10% CPOE usage since “CPOE is traditionally one of the last capabilities implemented at hospitals.” (like, decades after buying it?) Practices, most of them considering their first EMR in a quick ramp-up to earn HITECH money, need 80% usage right out of the gate. I expect changes here, too, with the hospital target raised and the practice one lowered.
• With the minimal CPOE usage required for hospitals, the five required (and undefined) clinical decision support rules won’t have much impact on patient outcomes.
• The report cites a pseudo-fact that, “Some vendors have estimated that EHRs could result in cost savings of between $100 and $200 per patient per year.” Vendors say a lot of things, but I believe only those that are enumerated in a contract, preferably with rewards or penalties to encourage backing up self-serving statements with risk. I’m not sure I would have included that stat.
• The report used the high estimate of EHR cost from a range of $25,000 to $54,000 per provider, stating that “we believe the cost of such technology will be increasing.” Why should software costs increase when user bases are increasing, which should allow vendors to spread their fixed software development costs over more users? The only one factor that would raise the price is the vendor cost of complying with certification requirements (government meddling in free markets never comes free).
• That higher upfront EMR cost makes the elusive $44K jackpot even less enticing. Doctors were already avoiding EMRs because of cost and negative workflow impact. Providers are questioning whether they can qualify for the incentives and whether they trust the government to pay them.
• Conclusion: if you like the idea of having the government use taxpayer money to encourage the use of specific products in the pursuit of lofty and possibly unrelated goals, this at least pushes some theoretical behavior change in the users who choose to participate. If you’re a provider trying to decide whether the government money has too many strings attached, this might convince you that it does. And if you asked me how the odds of high EMR utilization changed with the release of these proposed requirements, I’d say they got worse.

I can’t help but repost something that HISTalk posted about one of the companies that’s now CCHIT preliminary ARRA certified and the meaning of said certification:

From Lester Bangs: “Re: ARRA certification. Companies like this one (and they aren’t alone) get checked off on SOME of the ARRA criteria (which are changing) and get labeled as Pre-ARRA Certified by CCHIT. Amazing. And we wonder how folks are confused.” I found CCHIT’s disclaimer more interesting (click the above screen shot to enlarge) since it clarifies that the certification is preliminary, possibly irrelevant depending on the standards that are eventually approved, and possibly worthless since CCHIT may not even be a recognized certification body by them.

I’ve always loved HISTalk, but I’m even happier to see that him and I agree about CCHIT certification. I’m sure Mark Leavitt is really glad he’s cutting out of CCHIT when he did.

Healthcare Informatics has been doing a number of really interesting interviews lately. One of their most recent ones is an interview with RiK Drummond, CEO of The Drummond Group. You may have seen that the Drummond Group will be certifying EHR for ARRA funding. So the interview with Rik Drummond is pretty interesting. It is in 2 parts, but here are some highlights from the first part (since the second part isn’t up yet):

In regards to the cost of EHR certification (looks like Drummond Group EHR certification could still be pricey):

GUERRA: So you don’t have a better sense of whether they feel the current pricing is too high or if the certification process is too long? You’re not getting a more definite sense of what it is they’re coming to you for?

DRUMMOND: We’ve been kind of overwhelmed with a lot of this for the last three or four weeks, so we’re going back to interview some of them just to see what the actual problem is. I should know more in probably three or four weeks.

I expect that this is like normal testing where pricing is always an issue. Every test that anyone does, people think it’s too high because it’s one more cost to add in the end. The flipside is we find that once people understand what pricing gives them – it’s almost the last part of their software cycle – they see the cost is not nearly as high as they would anticipate, because it’s a cost of shifting from internal testing to external testing, and it also gives them a big marketing boon because someone is stamping their seal of approval on you, you’ve met these conditions. And that marketing boon is worth anything, you pay for that sort of thing.

In regards to establishing the EHR criteria and CCHIT certification (glad to see they like the separation of requirements making and requirements testing):

DRUMMOND: We think it’s very important to keep the stakeholder groups who define the requirement areas distinct from the testing parts, if at all possible. That doesn’t mean it can’t be the same organization, but it means you have to have some really clear boundaries. So CCHIT has both of those combined, and we always try to avoid having those two combined very closely.

Our focus would be very much on working with CCHIT, our working in parallel with them, but we all have to use exactly the same test criteria to make this whole thing work. So it has to be defined somehow so that happens. We need to focus on the technical aspects in making everything come together appropriately, so that when people go buy these products they can say, “Well, I’m one step into meaningful use. I have one key component in place. Now, I have to show how I use it to get the rest of it.”

There’s been a series of posts done on EMR and HIPAA that I think are worth highlighting on this site. They basically cover the status of where we’re at in understanding what will be defined as “certified EHR” in order to get the ARRA EHR stimulus money.

First, take a look a post talking about the HIT Policy committee meeting on EHR certification where they discussed and approved a number of items related to defining certified EHR.

After that initial meeting, CCHIT held a town hall meeting to present their new CCHIT Preliminary ARRA Certified EHR certification plan. Then, take a look at a bit of a comparison of the Preliminary ARRA Certified and CCHIT Certified that was presented at the same meeting.

Finally, no discussion of these EHR certifications is complete without taking a look at the costs for the new CCHIT EHR certifications. That link also discusses the new EHR certification bodies that are likely to be created and recognized by HHS to be able to certify EHR software in order to obtain the ARRA EHR stimulus money.