This is the third post in the series of posts(see the previous ONC-ATCB Certified EHR Breakdown and ONC-ATCB Certified EHR Breakdown by Certifying Body) looking at the EHR certification numbers put together by HITECH Answers. The following is a list of Certified EHR products by vendor:

Top 3 Vendors by number of Products Certified
- Cerner Corporation – 13 products
- Siemens Medical Solutions USA Inc – 9 products
- Epic Systems Corporation – 4 products

I guess these are the EHR software you want to avoid. Ok, that’s partially facetious. Just, can you imagine trying to battle the other 12 certified EHR to get support. Granted, most of them are likely hospital EHR and so there are usually support contracts in place to deal with this kind of thing. Don’t worry though, Allscripts should be on this list soon. I think they have something like 7 EHR software for just ambulatory right now. I guess that’s the nature of acquisitions.

It will be interesting to continue to see this evolve.

This is the second post in the series of posts (see the previous ONC-ATCB Certified EHR Breakdown) looking at the EHR certification numbers put together by HITECH Answers. The following is the breakdown of EHR Certification by Certifying body:

2 Certified by Infogard
- 1 Modular Ambulatory system
- 1 Modular Inpatient system
40 Certified by Drummond
- 15 Complete Ambulatory systems
- 5 Complete Inpatient systems
- 15 Modular Ambulatory systems
- 5 Modular Inpatient systems
88 Certified by CCHIT
- 50 Complete Ambulatory systems
- 15 Complete Inpatient systems
- 11 Modular Ambulatory systems
- 12 Modular Inpatient systems

Infogard is just getting started, but CCHIT and Drummond Group are cranking them out. I’m guessing right now demand for their service is strong and they can certify them as quick as they can. It will be interesting to see what happens to these organizations post EMR Stimulus money, but they have a few years before they have to worry about that.

Of course, this is only the temporary ONC EHR Certification. ONC will have the official one and then all the EMR vendors will likely have to re-certify again. Let’s call it the EHR certifying body stimulus program.

Many people were worried that we wouldn’t have many certified EHR available for 2011. I wasn’t one of those people, but they were out there. Seems to me that this really won’t be an issue at all. There’s 130 partial or complete EHR companies on the official ONC certified EHR list. That’s a lot of software and it’s only the beginning of December. I expect we’ll have 200 or so more ONC-ATCB certified EHR software by the first quarter of 2011.

The good people at HITECH Answers have done the hard work putting together the number of systems certified. Check out the numbers:
85 Complete EHR
- 65 Ambulatory systems
- 20 Inpatient systems
45 Modular EHR
- 27 Ambulatory systems
- 18 Inpatient systems

That’s right. 65 Complete Certified Ambulatory EHR. 27 other modular certified EHR and I’m sure that many of those are just doing the modular as a stepping stone to the full certification.

We have all seen medical records from an emergency department (my apologies to the blissful ignorant out there — you don’t want to know if you don’t already). Much like sausage, they come out pretty much all ground up, full of information that at first glance can be difficult to figure out. If you find yourself asking questions such as, “Where is the part about why the patient came in and what the doctor thought about their case?” then you just might have one of these notes. They’re actually one of my favorite types of “old medical records” to sift through for the purposes of “reviewing and summarizing”. This is because when you’re dealing with gobbledygook, well, there’s not much to summarize. It’s easy to flip through forty or fifty pages in no time and say that you have honestly reviewed and summarized the old records, which are full of near meaninglessness that doesn’t impact my decisions in the patient’s care much, if at all.

The ER notes (and many primary doctor visit notes nowadays) result from having programmers who don’t appear to understand the appeal of a well-written note in facilitating basic communication. Computer programmers who get their hands on the list of required information that must be put into a note to pass by insurance standards don’t always design good products. Unfortunately, this really only highlights the insanity of criteria for medical documentation to gain the golden eggs of insurance company reimbursements for providing medical services. I’ll save those crazy criteria for some other day. Nonetheless, the tax man and the gobbledygook cometh. If only they had the guidance of a practicing physician in the design process!

Unfortunately, as the gold rush for economic stimulus dollars ramps up, poorly designed systems will most assuredly continue to be thrown onto the market. I recommend to anyone considering incorporating an EHR system into your practice that you actually consider and request to review a sample of the output format. If it looks like something that would embarrass you to show your former mentors from the residency or fellowship program in which you trained, then I would posit that this is probably not fit for medical documentation. If no one wants to read what you wrote, then is it really worth doing? And please don’t be fooled into thinking that spending more money is the key to getting a better product. Ask the EHR vendors to put their money where their mouth is.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

I’ve discussed on multiple occasions the possible impacts of the congressional changes on the EMR stimulus money. Justin Barnes on The Health Care Blog recently posted the best reason I’ve seen yet for the EMR stimulus money and meaningful use being safe from being cut, stopped, or otherwise maimed due to some political change. Here’s his description:

Fundamentally it’s important to note that the Health Information Technology for Economic and Clinical Health (HITECH) Act, from which the Meaningful Use program and its funding originates within the American Recovery and Reinvestment Act (ARRA) of 2009, is an entirely different statute than PPACA.

Bipartisan support for the tenets and the spirit of HITECH dates back at least seven years, and it is also noteworthy that the Office of the National Coordinator for Health Information Technology (ONC), which administers Meaningful Use, was created by the Bush administration and a Republican Congress.

Politics aside though, the reason that Meaningful Use funds are secure is because they are drawn from the Medicare Trust Funds held by the U.S. Treasury, and are therefore not subject to annual Congressional budget appropriations or oversight.

From what I’ve read, the funding is really the only tool that the republicans have to damage the various democratic legislation that they don’t like. Since the meaningful use funds are part of the Medicare Trust Funds and not subject to the congressional budget, I think that clearly defines why the EMR stimulus money is safe.

So, you can all go out and safely buy your certified EHR and start showing meaningful use of your favorite EHR software.

HIMSS Analytics recently sent out some interesting results from a survey the did of hospital’s preparation for meaningful use. Here’s the results:

*Nearly one quarter (22 percent) of participating hospitals have the capability to achieve 10 or more of the required core measures in the meaningful use Stage 1 requirements.

*Some 34 percent of respondents have the capability to achieve between five and nine of the core measures for meaningful use.

*Just over 40 percent (40.47 percent) of the market indicated they have the capability to meet five or more of the menu items for meaningful use.

As lone data points it’s hard to judge if hospitals are making progress or not. I’ve heard many people say that hospitals are going full bore towards meaningful use and that ambulatory practices are slower to adopt EMR and meaningful use. I’m not sure this is totally true. Plus, the lead time needed to implement in an ambulatory setting is so much shorter than in a hospital. Even a hospital that owns ambulatory practices.

I’m told that HIMSS Analytics will be doing this same survey every couple months. I’ll see about publishing the results as I get them so we can compare the change.

Check out this 4 and a half minute video that talks about the details of the EMR Stimulus (HITECH Act) EMR stimulus money. This is by far the best EMR stimulus video I’ve seen that gives a nice high level overview of the HITECH act. I hope that they do some other similar videos with more details on meaningful use and certified EHR since this is the only meaningful use video I’ve found.

If you know a lot about the HITECH act, you won’t enjoy this video. However, doctors who don’t know too much about the EMR stimulus money and how the HITECH act works will enjoy it.

Gov Info Security recently published their thoughts on the possible effects of the new Congress on the EHR incentive money known as the HITECH act.

Republicans, however, have made it clear that they’ll look for any opportunity to repeal some or all of the healthcare reform package. Observers say that means the HITECH Act likely won’t get as much attention, even though the EHR incentives are funded by President Obama’s economic stimulus package.
“One of the things that the Republican ‘pledge to America’ includes is a plan to take away any unobligated stimulus money,” says Dave Roberts, vice president of government relations at the Healthcare Information and Management Systems Society. “I don’t think that’s going to apply to the HITECH provisions. Folks on the Hill tell me that health IT is a bipartisan issue. Democrats and Republicans see it as a way to improve healthcare.”

Nevertheless, Republicans will closely scrutinize all spending, Roberts acknowledges. “And they’re going to take a close look at all the provisions of the HITECH Act to make sure they’re being implemented as directed by Congress.”

Even if the presumed new speaker of the House, John Boehner, R-Ohio, was to push for spending cuts, such as eliminating the EHR incentives, getting such a proposal approved would prove very difficult, Roberts argues. “With the two chambers of Congress controlled by different parties, getting them to agree on something will be next to impossible,” he says.

In addition, President Obama, who is strongly supportive of healthcare IT, likely would veto any cuts in HITECH spending, notes Rob Tennant, senior policy adviser for the Medical Group Management Association. And overriding a veto would prove extremely difficult.

I tend to agree. Certainly something crazy could happen (it’s government work after all), but I think the likelihood of HITECH Act funding being taken away is pretty slim. As it describes above, it would take a really unique piece of legislation to get it through the house, senate and then the President. I just don’t see that happening at all.

Plus, I thought the point of the money being so far along in the regulation process is another good reason. Although, since checks haven’t been paid out yet, I’m guessing that there’s still potential that they’ll put it on hold. Just seems really unlikely to me.

Many in the health care IT and EMR world have been waiting to see the election results from last night. There’s been a reasonable fear about what impact the election results might have on the EMR stimulus money and other healthcare IT policies. The HIMSS blog described some of the details of the changes we saw last night:

The United States Senate has stayed in Democratic control, but with a much smaller majority. Senate Majority Leader Reid from Nevada survived a tough re-election, but is much weakened going forward. Senate Democrats will now have to look at whom they want to lead the Senate over the next two years. They will vote by secret ballot in the near future.

The United States House of Representatives will now be controlled by the Republicans when the 112th Congress convenes in January 2011. President Obama called the presumptive next Speaker of the House, Rep. John Boehner, last evening to congratulate him on his party’s victory and promise to work with him. With the House and Senate held by different parties, compromise will be even harder to find in the 112th Congress.

The current 111th Congress will reconvene in a few weeks to complete unfinished business before adjourning permanently either this month or next month.

I’m not so sure I agree that Reid has been weakened so much by the results of this election. He won and he’s seen as a guy who is great at strategy in Washington. So, I have a feeling that he’ll be back as Senate Majority leader again with just as much power. I say this as someone living in Nevada.

This part aside, I think the fact that the Republicans only took control of the house and not the senate likely is a good thing for the EMR stimulus. I heard one person tell me that the EMR stimulus money has pretty good bipartisan support in the government. I think this is generally true and that it will only be taken away if it’s a casualty of the unspent ARRA stimulus money and not because they specifically didn’t want to spend money on EMR.

I still think this is a possibility, but I personally believe it’s a small possibility. I don’t think the Senate will really allow that to happen. Instead they’ll focus on other things (possibly healthcare reform instead).

I’m interested to hear what other people think. What other effects will the election have on healthcare IT policy?

My previous post about the RECs possible failure has brought on some really in depth discussion on the topic of RECs and the challenges and opportunities they face. I encourage you to go and read all of the comments and join in on the conversation, but here’s a few of the in depth comments on that thread (since I know that many of you don’t read the comments):

Margarlit Gur-Arie, from On Health Care Technology, started the discussion with these comments:

1) Doctor’s aren’t moving as fast as the money is flowing
The money is NOT flowing independent of the docs’ movement. The money only flows AFTER a particular doc decides to “move”. RECs are operating on a P4P model.

2) The market already delivers on what RECs promise
The REC promises to touch every single small practice in rural and underserved areas. The market was never able to do so because the cost of selling to these docs was way to high. The RECs also promise to deliver about $5000 in consulting services to each provider practically for free and no strings attached. The market never in its wildest dreams offered anything like that.

3) “Preferred vendor lists” limit choice and free markets
Every consultant employed by a practice usually narrows the choices down based on research and knowledge of the market (some do it for kick-back). The RECs are going through a process to establish vendors capabilities and willingness to serve a particular State needs. The “free market” is just fine. The RECs are operating within that market. Not to mention that RECs only make recommendations. They will work with any vendor that a particular provider chooses.

4) RECs won’t get doctors to “meaningful use” fast enough
Fast enough for what? Incentives? I thought doing a good job at selecting and implementing a proper EHR is more important than a few thousand dollars handout. The goal is for the use to be meaningful to the practice. The rest will take care of itself.

5) The REC model leads to under-staffed, ephemeral entities
How so? Every start-up starts small. Some grow bigger and some die. This is exactly what will happen to these 62 start-ups. I’ve seen RECs hire and train pretty talented folks in rural areas. Salaries expectations are lower and with the current unemployment, it doesn’t seem to be such a monumental task to find good talent if you know where to look. I actually think that RECs are in a better position to find talent than national vendors.

Nothing is ever perfect, and as you know, I have been critical of many other “initiatives”, but I think that the REC concept is a valiant attempt to reduce disparities and bring technology and better health care to traditionally neglected populations and their equally neglected doctors. This is the #1 reason I want to see the RECs succeed.

My response was the following:

1. So, it’s poorly worded. The fact doctors are too slow to implement EMR means the RECs won’t be able to “perform” and won’t see money flowing.

2. Where did you get that RECs are touching “every single small practice in rural and underserved areas.” I’ve seen them mostly operating in big cities. Is there part of their mandate that I’m not remembering? $5000 in biased consulting is not a benefit to the market. Sure, some RECs are providing quality service, but many are playing the numbers game.

3. Another one that’s poorly worded. Of course the free market can still work. In fact, it will continue to work even if doctors select a bunch of unusable EMR. It will just take a long while for it to correct that mistake. The idea of a preferred vendor list is messed up though. Why would a doctor ever leave it up to another organization to go through the EMR vendor selection process for them. It’s an impossible task to try and have a preferred vendor list when you’re representing such a diverse population. There were much better options than what most have done. Props to the RECs who have indeed stayed vendor neutral and avoided even the appearance of impropriety.

4. If RECs focus too much on providing something meaningful to the practice they’ll miss their P4P goals and then they’ll end up leaving the doctors who they were trying to help all alone with no where to turn. Or doctors will have to start paying for the service they were told was going to be free.

5. Scaling up quality staff is an incredibly hard job in any industry. Getting quality staff to come and work at a REC that may or may not exist and therefore you may or may not have a job in a year is a challenge. It’s not impossible, but is a HUGE barrier to overcome.

Of course, I’m playing devil’s advocate above. I don’t think that EVERYTHING that the RECs are doing is terrible. In fact, there are some really sincere and smart people that I’ve met that are working at the RECs. BobbyG on this thread being one of them.

Maybe one of the bright spots of the RECs is that it’s at training ground for smart people like BobbyG to get experience and connections that will allow them to be some of the future leaders in really pushing forward EHR adoption. It just seems like the money could have accomplished the same thing and better spent other ways.

Margarlit then replied:

1) If the docs don’t adopt and the RECs don’t get money, the tax payers get to keep the funds. That is as it should be.

2) Part of the RECs mandate is to service underserved and rural populations. There are plenty underserved in big cities I guess, but the intent was not to serve Cardiologists in Beverly Hills. It is exclusively about Priority Primary Care Providers (small practice & underserved). If the RECs don’t go where they were directed to go, that’s a completely different story.
Why are you assuming that the consulting is biased? What possible incentive could a REC have to be biased? Unlike many “consultants”, they don’t make more money based on a physician’s EHR choice.

3) The population served is not as diverse as you may think. Primary Care docs in small practice – that’s all the RECs currently represent. I think you know as well as I do that the main reason for EHR failure is not really the software, but the lack of planning and change management and here is where the $5000 should be spent. There are happy users for any given EHR and there are miserable failures for the same software in the exact same type of clinic. This is what needs to be addressed.

4) Most RECs are signing docs on a yearly subscription basis. We all know that a PCP small practice can be successfully implemented and brought to Meaningful Use in 3 to 4 months start to end. I don’t see a problem here. MU is really not anything too terribly onerous for Stage 1.

5) Yes, scaling up with good talent is hard. But remember, John, some of the REC grants went to entities that were already staffed (NY is a good example), other went to Universities and others to Quality Improvement organizations. Very few are starting from scratch.

All that said, I don’t think this REC business is a walk in the park and I fully expect a big chunk of RECs to disappear after 2012. But the ones that survive will be very strong and very useful public resources.

As to the EHR vendor market, there are many benefits to the docs and their patients in areas where one EHR has a large presence, particularly if it is a decent product (see eCW in NY). To be honest, I am not too terribly concerned with how vendors fare. I am more concerned with enabling information exchange and quality improvements on behalf of patients. It is easier to accomplish that with a handful of vendors instead of a gazillion disparate systems, some of which will surely go under.
Yes, we could wait for the perfect EHR to come along, but I have a funny feeling it never will, so why not do the best we can with whatever is available now? We can always make adjustments as technology grows and improves.
Right now, if we are to put a dent in the 17% GDP consumed by health care, clinical information exchange is imperative, even if it’s not perfect.

I then posted this response:

My take on the bias of RECs is that if they have a preferred EHR vendor then by its very nature it’s biased. Plus, it’s creating a bias in what I consider to be the most important part of an EMR implementation process: the EMR software selection.

So, while I do agree with you that poor planning leads to some failures, I don’t think it’s the main cause of failure. I actually think selecting the right EMR and the process that’s used to select the right EMR is the key to a successful implementation.

Part of my reasoning for this is that selecting the right EMR and having the right process for selecting an EMR creates a clinical buy in that pays off in spades when you get into the dirty details of implementing an EMR. I think lack of clinical buy in is what leads to most EMR implementation failures and that’s often directly related to the EMR selection process.

I guess that’s why I get my pantyhose all bunched up when I see the EMR selection process tainted.

Certainly a doctor could get up and running and show meaningful use in 3-4 months, but that’s going to be the rare exception. Life and their practice gets in the way and makes it take much longer. Plus, these time frames start once the providers have firmly decided to make the jump. It’s that decision that slows the process more than anything.

I don’t care about the EHR vendor market either, but I do care that the best software is implemented by doctors since that is what will lead to the best patient care and patient outcomes. I don’t want the EMR vendors to be implemented just because they have great marketers.

Health information exchange is great, but until we have them using EMR’s it’s not even a possibility. A bunch of doctors implementing unusable EMR software which they hate will do more to hamper the widespread adoption of EMR software than anything else. This is why I’m so passionate about the best EMR software being implemented. Otherwise, it will take a lot longer to reach the health information exchange nirvana.

Margalit then answered:

The REC recommended list should be created through a stringent screening process which includes RFPs, demos and I’ve heard of one very large REC which has a usability lab just for this purpose. I would hardly call this process “tainted”, particularly since the screenings seem to be performed by practicing physicians.

To David’s point, the recommended list is just the beginning. Each individual practice is then expected to go through the usual vendor selection process and any and all certified EHRs will be considered. As David noted, RECs are obligated to work with any ONC certified EHR and the particular brand will not in any way affect their payments.

I think the RECs bring to the table resources for screening vendors that a solo practitioner does not have. They are also bringing with them certain strength in negotiating favorable contractual terms with recommended vendors. This must be a good thing for the docs.
Will this change the vendor landscape to a certain degree? Yes, I believe it will, but I also believe that the vendor landscape is in dire need of some changing.

I answered:

“The REC recommended list should be created through a stringent screening process”[emphasis mine]

The problem is that many of them haven’t been stringent.

Another “should” is the RECs working with a doctor that has any certified EHR. Of course they will work with them. They need their numbers. The question is what value will they provide that physician? Physicians who don’t use their preferred EHR vendor list won’t be motivated to work with the RECs. Not to mention the overall distrust of the RECs that I’ve seen from physicians.

Margalit,
I agree that they could have used the group buying power for some real good in negotiating favorable contract terms with an EHR vendor. I just wish that they’d actually asked the doctors whom they represent which EHR vendors they should negotiate with. This would have dramatically changed my view of RECs and what they could have offered.

Just remember that change doesn’t always mean a change for good. It could be a change to something worse. I learned that very early on when I had a boss who was less than favorable. Turned out he had his weaknesses, but his future replacement had even more. Fine lesson learned.

Of course, there were some comments in between as well that are definitely worth reading. Go and read the whole thread to see what I mean.

Who said I don’t write long posts on my blogs? lol