Welcome to EMR and EHR

Ever since I first saw Fred Trotter’s post about CONNECT being the future of EMR interoperability, I was really interested in the open source software CONNECT. Of course, when the PR person from ONC emailed me with an opportunity to talk with someone from ONC, I jumped at the chance.

The following is a short video where I tried to capture what ONC is doing with NHIN and CONNECT so that people can be more informed on these 2 projects. I hope you enjoy:

This video coverage of HIMSS 10 sponsored by Practice Fusion and their Free EMR.

I just found this really nice interview by InformationWeek with David Blumenthal, Health IT Czar. Here are a few snippets of what David Blumenthal said with my own commentary in italics.

Congress set very ambitious goals for the HITECH legislation. The concept of meaningful use is novel, and a very powerful and important concept. The process of defining meaningful use has gone through many months, through many public hearings.

I think David Blumenthal realizes that meaningful use is going to be a major problem for many doctors offices. I think we’re going to hear him blaming Congress for the “ambitious” HITECH legislation which has his hands tied. It probably does, but it’s too bad he can’t just say it that way if it is the case.

The Office of National Coordinator is still committed to developing the Nationwide Health Information Network. Many of our federal colleagues and quite a number of larger healthcare organizations are on the verge of using NHIN as it was originally conceived and configured for their own purposes, and we’re continuing to invest in it.

At its last meeting the HIT Policy Committee adopted recommendations that they have not yet formally transmitted to me to encourage the development of a more flexible, adaptable, less complicated method of health information exchange than the Nationwide Health Information Network. And that’s something that we’ll be studying.

I think this is a good move. This national network in its current state just doesn’t seem like it’s going to have much affect on small doctors offices, which last I checked make up a large part of our healthcare system. I think in politics they call this move taking it to the people.

InformationWeek: Once you get clinicians using e-medical records, who pays to maintain the exchange infrastructure?

Blumenthal: It’s a short-term issue. Long term it’s going to become an expectation on the part of the clinician and patient that information is going to be exchanged. And I think it will become a cost of doing business in the healthcare sector just as physicians and nurses consider it a cost of doing business to buy stethoscopes and run an office.

Doctors will hate to hear this quote. Although, they shouldn’t be too upset. In reality, they’ll be passing this cost on to the consumers. Now how we get to the point Blumenthal talks about is beyond me. That’s a huge gap to cross.

InformationWeek: Will the Certification Commission for Heath IT–CCHIT– remain the organization doing these certifications, or will there be others?

Blumenthal: We’ll have to see what the regulation actually is and see where CCHIT fits in. CCHIT is clearly going to have the option to participate in certification going forward, but I can’t tell you what role exactly it will play.

Translation: I don’t care about CCHIT. If they want to participate great, but I’m playing no favorites here.

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.

A while back I wrote about the great news that the Drummond Group was planning to compete with CCHIT in doing EHR certification. The news coming out of HHS has been slow coming for these new EHR certification bodies, but I just received this email from the Drummond Group. In it they assert that they’re still planning to become an EHR certifying body for purposes of getting EMR stimulus money. Below is the full email:

As our 2009 year closes, we wanted to reach out to the many EHR vendors and interested parties who have contacted us about EHR certification and update you on the current state of our EHR certification program. Like you, we are currently waiting for HHS to release their meaningful use definitions and, just as importantly, their certification requirements. In his recent blog post (http://healthit.hhs.gov/blog/onc/index.php/2009/12/07/marking-the-road-ahead/), Dr. Blumenthal of the ONC indicated the publishing of the plans for the new certification program will not be released until early 2010. This is a bit disappointing as we were expecting this in late 2009. Regardless, we remain very excited about the future of EHR certification.

In this period of waiting, we have been speaking to many industry leaders and stakeholders to gain as much information as we can to ensure our EHR certification program will meet the needs of end-users and be viable for EHR vendors, especially small and medium sized companies. Once we get news of the HHS certification program, we can begin formalizing our EHR certification process. When we know more, we will make sure we keep you updated about our plans.

Thank you for your interest in us and EHR certification. May you and yours have a joyous holiday season and an even better 2010.

Joani Hughes
Interop Certification Coordinator
Drummond Group Inc.
www.drummondgroup.com

There’s been a lot of talk around the blogosphere about the new EHR certification pathways proposed by CCHIT. However, Neil Versel is reporting on his blog that there’s a rumor that ONC is planning a July meeting with several people that are considering starting up an EHR certification program.

Makes complete sense to me. David Blumenthal does seem open to the idea of not having CCHIT be the sole certification body. Certainly he’ll feel some big time pressure from the various big EHR vendors out there, but I’m hopeful that David Blumenthal will be able to do well and keep at least some competition in the EHR certification process.

Everyone in the healthcare IT world is sitting and waiting to know the fate of the words “certified EHR” and “meaningful use.” Yes, only a few billion dollars of EHR stimulus money are riding on those 2 terms.

Well, after the Health IT Policy Committee came out with their initial set of recommendations, it was reported that David Blumenthal, National Coordinator for Health IT, said “lively discussion (on the criteria) and considerable input on meaningful use, we decided to send the work group back to work on another set.”

Looks like the new date for more guidance from the Health IT policy committee will be their July 16th meeting.