HITECH Answers recently posted a great post that gives a run down of the EHR Incentive program’s progress in 2011. Here’s their list with my own analysis and commentary of each point.

123,921 Eligible Professionals have registered for EHR Incentives, 15,255 have successfully attested to meaningful use in the Medicare program.
This seems like such a HUGE difference in numbers. That’s just over 12% of Eligible Professionals that registered attested to meaningful use. Does this mean that we’re going to see a tidal wave of meaningful use attestation in 2012? Possibly.

I believe that we’ll see more eligible professionals attesting to meaningful use in 2012. However, the question is how many of those other 108,666 will attest to meaningful use in 2012 and how many are like the Happy EMR Doctor who just registered to see the MU process. I wonder how many first hand meaningful use experiences by doctors will scare doctors away from MU attestation.

3.077 Eligible Hospitals have registered EHR Incentives and 604 of those have successfully attested to meaningful use.
This is almost 20% of hospitals that have registered that have attested to meaningful use. It’s not surprising that this number is a lot higher than eligible professionals. I still believe that the wave of meaningful use attestation will come from these other 2473 hospitals and probably many more that still haven’t registered. I haven’t seen a good number of how many hospitals are in the US. Does anyone know that number? The EHR incentive money that goes to hospitals will dwarf those of eligible professionals.

$2,533,689,145 has been paid out in Medicare and Medicaid Incentives.
$2.5 billion sent out in 2011. I just went back to the first time I tagged meaningful use on this site on April 3, 2009 (coincidentally I have 19 pages of 10 posts each tagged with Meaningful Use). Amazing to think that it’s taken basically 3 years to spend $2.5 billion on EHR.

277 hospitals have received payments under both Medicare and Medicaid and of those 12 were CAHs.
That’s about half of the hospitals that have attested to meaningful use under Medicare are also getting the Medicaid EHR incentive money as well.

22% of eligible professionals that have been paid EHR incentives are Family Practitioners and 20% are Internal Medicine.
I must admit that I would have thought that the percentage of family doctors that got paid EHR incentive money would have been a lot higher. I guess when you have so many other specialty areas I shouldn’t be that surprised. I also wonder why the internal medicine number is so high. These numbers actually make me believe that a lot of family practice doctors are sitting out when it comes to meaningful use.

41 States Medicaid programs were open for registration. Two additional States launched in January of 2012.
I wonder what’s holding back the other 7 states. From what I’ve seen all the states will eventually get there.

More than 1500 EHR products have been certified by ONC-ATCBs.
That’s a lot of EHR software. I still put the EHR company list at about 300 EHR vendors. 1500 includes multiple versions of the same software, partial EHR certification for products like data warehouses, ePrescribing, etc. The best thing that’s come from the ONC-ATCB program is that it has made EHR certification basically irrelevant in the EHR selection process. Every EHR vendor is certified now. This is much better than the false assurances that EHR certification provided before. I still dislike what EHR certification has done to the industry, but at least it’s not misleading doctors the same way it was before.

Next up in our evaluation of the various end of 2011 Health IT lists series is one that takes a bit of a look back at 2011. In this list, PwC lists what they consider the Top Health Industry Issues of 2011. The list starts with an interesting comment about the health IT spending in 2011:

More than $88.6 billion was spent by providers in 2010 on developing and implementing electronic health records (EHRs), health information exchanges (HIEs) and other initiatives. This surge is a sign of technology’s critical place in health system improvement.

$88.6 billion is a lot of health IT spending and larger than most numbers I’ve seen. Although, most numbers I’ve seen are only the EMR and EHR market and doesn’t include HIE spending and other healthcare IT initiatives. It’s quite clear that the health IT spending is up, and up Big!

Their list of top Health issues isn’t that surprising, except possibly one of them:

Meaningful Use – This has to be topic number one for health IT in 2011. It’s had a trans formative effect on healthcare IT and EMR and EHR as we know them. Pretty much every EHR vendor I’ve talked to basically had to take an entire software development life cycle to meet the meaningful use and certified EHR requirements. This is the dramatic effect of meaningful use on EHR development.

PwC actually focuses on how meaningful use will encourage patient participation in their healthcare or “shared medical decision-making.” To be honest, I’m not sure meaningful use has done much to help this goal, yet(?). Possibly meaningful use stage 2 and meaningful use stage 3 will help to further these goals. MU stage 1 has done little to encourage this. Regardless of the impact of meaningful use, shared medical decision-making is going forward fast and furious.

HIPAA 5010 and ICD-10 – The interesting issue for 5010 and ICD-10 is that they’ve basically been overwhelmed by meaningful use and EHR incentive money. Either of these changes alone would have been a reasonable challenge for a normal year. However, clinical organizations are battling through 5010, ICD-10 and meaningful use all at the same time. Are there any other IT projects going on that don’t involved these three things? I’d say probably very few.

Electronic medical device reporting (eMDR) – I found this point quite interesting. There’s been a lot of movement in 2011 in regards to what constitutes a medical device and who should take care of tracking and collecting the adverse events that occur on these devices. I don’t think we’ve come to a final conclusion on what will be considered a medical device and how we’re going to deal with reporting adverse events, but finally getting electronic reporting of adverse events is a good step in the right direction.

Be sure to read the rest of my Health IT Top 10 as they’re posted.

The following was a comment made on my previous post about Meaningful Use attestation issues by Jon (man there are a lot of John/Jon’s in Health IT). As always, I do my best to bring out interesting topics for all to read. In this rant, Jon makes some interesting comments about the challenge of specialty EHR software to meet the MU measures. Something I’ve mentioned before, but Jon adds some more insight.

*start rant*

It is even worse for some small EHR vendors that have existed for over 20 years – like the one I work for. The government has no idea how ugly and not applicable many key elements of meaningful use (defined as the government chooses) are for non-primary care, highly specialized providers.

Here’s a conundrum that frames EHR certification and meaningful use in a way I rarely see it discussed (and would love for someone to explore more *hint hint*) – take a small, but established vendor of EHR software which is not yet certified.

This vendor provides software to a niche industry of highly specialized providers, who do not derive any real or identifiable value from meaningful use as it is defined (to keep things generic I will omit the specific part of the industry).

To get software 100% EHR certified you must fulfill all of the requirements, even if, as a vendor, your customers will not make use of, or benefit from, most of the functionality. Please take as an assumption (for this discussion) that only 30-40% of the EHR certification requirements are of value to the customer.

Since the customer will not make use of the functionality, they don’t want really want to pay for a 100% EHR certified product. But they sure would like the incentive money (or in the case of Medicare providers, will get penalized if they didn’t do meaningful use).

As a small vendor, your big competitors are all EHR certified (and some are even free), but even if it didn’t make sense for the customer – because the other (typically larger) vendor can afford to implement it, even if it is sloppy. Customers see a well-known product name from a large company is EHR certified – so EHR certification gives those who complete it an edge – even if it makes zero financial or functional sense.

I hate being a pessimist, as surely some good has come from meaningful use. However, as we are seeing by these posts, what value does EHR certification and meaningful use TRULY bring to the provider, other than the requisite piece of paper to get incentive money? We need to see many, many more successes, and in my specific case, we need to make sense of how to make something which is not useful… useful somehow.

Sure, the answer to this might be that in the long run, vendors with better or more applicable products will always win out, but we know that this isn’t always true based on long-term software contracts or lack of desire to switch vendors. Or the answer might be that highly specialized providers only account for 20% or less, and 80% of the provider population is primary care or similar handle meaningful use just fine. Or maybe that I’m just crying in my beer!

Nevertheless, we have this catch-22.. or an enigma wrapped in a mystery shrouded in a riddle.

*end rant* Comments? Thoughts?

One other note from John Lynn, I’m sure many large EHR vendors will probably say that if small EHR vendors can’t meet the MU requirements, then they don’t deserve to be an EHR software. Those that say this, are really missing the point. It’s not that they couldn’t meet the MU requirements, it’s a question of should they meet them in MU’s current state.

What else could be written about meaningful use that hasn’t already been said? Really. I’ve been thinking this over since I think we’ve been writing about the EHR incentive money and meaningful use for almost two years now.

I still remember the first time I read about the government planning to give out incentive money for those who adopt an EMR. Some thought that they’d just give out the money to doctors who adopt an EHR kind of like they did for those who purchased a home. I guess the government assumes that when you purchase a home you’re going to use it, but when you purchase an EHR that’s not always the case. So, meaningful use was born.

One of my biggest problems with meaningful use has always been its conflict with certified EHR. I’ll never understand why the government wants to certify EHR software (ie. more expense) when they could have just built the requirements of meaningful use so that the only way for a user to meet the requirements is by using an EHR software that performed the functions required. I guess I can partially see some security checks that could be done in an EHR certification that wouldn’t show in meaningful use, but does anyone really think that EHR software is much more secure thanks to EHR certification?

Of course, much of this is water under a bridge. We have meaningful use and certified EHR and there’s no going back now.

At this point, I wonder how many doctors are still undecided on meaningful use and EHR software. Considering all the discussion and chatter, I feel like most doctors have made the decision on the subject. They’re either going to use an EHR or not. I guess there might b e a few doctors that want to use an EHR, but are waiting for the right one. Certainly there are many doctors that know that EHR is the future, but they just haven’t committed the time to evaluating the various EHR software and deciding which one is best for their office.

My gut feeling tells me that the EHR incentive money wasn’t enough for many of them to finally get down to the business of selecting and implementing an EHR. I imagine many of them are waiting and hoping for a clear EHR market leader to emerge. I’m sorry to inform them that I don’t think that’s going to happen for another 2-3 years at least. Plus, I still think we might have market leaders in each medical specialty.

I’ve heard some argue that it’s the future meaningful use stages that have people scared to implement an EHR. Basically, they believe that meaningful use stage 1 is reasonable, but they think that meaningful use stage 2 & 3 will be much harder and not worth the effort. Kind of reminds me of the arguments that businesses have made about the uncertainty of economic policy causing them not to “move” on more investments. I think many doctors are uncertain about the EHR stimulus money, future stages of meaningful use, and how private insurance companies may react in the future. This uncertainty does cause issues for their ability to plan.

One thing I think the EHR industry could do to provide more comfort to doctors is to provide doctors that adopt your EHR a pathway to leave your EHR if you don’t meet their expectations. Why vendors try to lock someone into their EHR that hates it is beyond me. Ok, I get the short term gain and why you hate losing customers. However, by locking them into a product they don’t like you’re creating an eternal enemy to your product and believe me when I say that doctors talk. Plus, if you have doctors that want to leave because your product doesn’t meet their expectations, then you have a bigger issue on your hands. Sure one or two that have work flows that don’t match your product, fine. A mass exodus from your product because you chose to make it easy for them to leave means you should probably fold up shop anyway or fix the reasons why they want to leave.

Unfortunately, the large EHR vendors won’t really care at all. They’re all about lock in whether you like it or not. I hope doctors start to kick against this and support EHR vendors that provide pathways out of their product. I’d still be happy to support a movement to “liberate” EHR data. Any EHR vendors want to join?

This brings us back to meaningful use. It’s too bad the meaningful use didn’t require practical elements that would make a lot of sense for government to institute. For example…
-Require EHR vendors to create an easy export of all patient data
-Require EHR vendors to communicate with other EHR vendors
-Require EHR vendors to send public health data (they’ve kind of done this)

I’m sure there are more, but that’s a good start.

Now the most interesting thing is going to be how this first wave of meaningful use doctors react to the EHR software they’ve chosen. Unfortunately, I’ve really only seen meaningful use doctors who’ve had an EHR software well before the term meaningful use was coined. If you are a doctor who recently implemented an EHR post meaningful use, I’d love to hear from you so we can tell your story.

You’ve undoubtedly heard the argument before: EHR certification is about assuring that systems meet minimum requirements for functionality and interoperability, but the certification process falls way short in terms of usability, privacy and security. But have you heard the argument from one of the ONC-authorized certification bodies?

This is an excerpt from an e-mail I received today:

Meaningful Use criteria have become a massive EHR certification driver for healthcare organizations. Hospitals and other providers rely on the criteria to ensure that their health IT systems meet minimum government-specified functionality and interoperability requirements to support Stage 1 of Meaningful Use.  Achieving Meaningful Use also ensures a health care organization qualifies for reimbursement under the American Recovery and Reinvestment Act as a way to incent adoption of e-health processes among health organizations. The ultimate goal is to improve our nation’s healthcare system by leveraging technology to allow greater access to important health information and empower patients to securely access their own health information.

However, as one of only five organizations authorized to test both complete and modular EHRs by the Office of the National Coordinator (ONC) for Health IT, ICSA Labs questions whether EHR certifications are enough as the criteria represents only minimum requirements. Amit Trivedi, healthcare program manager at ICSA Labs, believes providers should take further steps to heighten the security and privacy of their health IT systems. He also suggests vendors should look beyond the current regulations to address and improve usability, data portability, and information exchange in their products.

That’s right, ICSA Labs, one of five organizations currently authorized to test and certify complete EHRs on behalf of the Office of the National Coordinator for Health Information Technology, seems to think that the standards it tests EHRs against are inadequate, which is something that critics of certification—particularly critics of the Certification Commission for Healthcare Information Technology—have been saying for years. Critics of many of the larger vendors have been saying that, too. But it’s shockingly refreshing to hear this from an actual certification body.

In fact, the publicist for ICSA, a unit of Verizon Business, has offered interviews with executives of two lesser-known vendors,  Health System Technology and Design Clinicals, to talk about how they are going beyond the minimum certification requirements. Deadlines beckon, so I didn’t really have time to wait for the publicist to try to find me an schedule opening for one of the executives, but here’s a statement from a March 30 ICSA press release that is somewhat telling:

“This year we are expanding our certification programs into health IT, a much-needed area of focus to help modernize today’s health care system,” said George Japak, managing director for ICSA Labs. “With our new focus on safeguarding patient information within electronic health records, we are committed to helping accelerate the adoption of health IT.”

We don’t hear too much about security in the context of certification from too many other camps, so it’s nice to hear that at least one certification organization is critical of the rules it is under contract to follow. Perhaps we’ll see tougher usability, privacy and security standards in the permanent certification program ONC needs to have in place by the beginning of 2012 to support the forthcoming Stage 2 “meaningful use” requirements from CMS.

Wishful thinking?

Once in a while, I run out of Big Ideas to share and resort to a rundown of short items. This is one of those times. Often, though, that approach turns out to be more interesting than a well-thought-out commentary. (Thus, the popularity of Twitter, right?)

Speaking of Big Ideas, I’m thinking that the age of the massive EMR project may be coming to an end. You may have seen my piece in InformationWeek today about the reported end of the national EMR in England. London’s The Independent reported earlier this week that the Cameron government will announce next month that it will scrap the national strategy in favor of allowing local hospitals and trusts to make independent EMR purchasing and implementation decisions.

This news comes on the heels of a decision by the government of Ontario to give up on hopes for a single EMR for all of Canada’s most populous province.

On the other hand, here in the States, we’ve seen a lot of consolidation among healthcare providers, but I’m guessing that has more to do with administrative Accountable Care Organizations and the prospect of bundled payments than any desire to build a more unified EMR. Though, consolidation does make health information exchange somewhat easier, and that’s going to be key to earning “meaningful use” dollars beyond 2013.

On a somewhat similar note, doesn’t a headline like, “Positive Outlook for Small Practice EHR Adoption” sound like a no-brainer? I mean, isn’t that the segment of healthcare providers that historically has had the slowest adoption rates? More than anyone else, small practices—particularly small, primary care practices—are the intended target of the federal EHR incentive program. And most of the news from health IT vendors of late has been about how they are going after this long-neglected market, right? The innovation seems to be happening in ambulatory EMRs, as evidenced by DrChrono’s newly certified iPad EHR app, aimed squarely at independent physicians.

That said, vendors and publicists, please do not start inundating me with news about other EHRs getting certified. There are hundreds of certified products out there now, and I cannot and will not write about, oh, about 95 percent of them.

While you’re at it, please stop using the word “solution” as a synonym for “product” or “service.” Tech journalists hate this trite, lazy and, frankly, inaccurate term so much that I’ve been instructed by the editors of InformationWeek not to use it, except in direct quotes. In fact, I get reminded not to use it pretty much every time I’m forwarded a press release laden with news about someone’s “solution.” Solution to what? I’ve been seeing that term since I started covering health IT more than a decade ago, and I still don’t see much getting solved in healthcare. With all the “solutions” out there, you’d think that healthcare had been fixed by now.

I could get a whole lot more curmudgeonly on you, but I think I’ll stop now and await your comments.

For those of you that are relatively new to EMR and HIPAA, you might not appreciate this post as much as long time readers of EMR and HIPAA. A few years back, I admit that I was pretty harsh on CCHIT and their EHR certification. I remember one guy stopping me at a conference and after realizing who I was asked, “so what’s your issue with CCHIT?” I was happy to answer that I thought they misled the industry (doctors in particular) by saying that the CCHIT certification provided an assurance that the EHR was a good EHR. They never came outright and said this, but that’s what EMR sales people would communicate during the sales process.

In fact, EHR certification was incorrectly seen by many doctors and practice managers as the stamp of approval on an EHR being of higher quality, more effective, easier to use, and was more likely to lead to a successful EHR implementation. EHR certification today still has some of these issues. However, the fact is that the EHR certification doesn’t certify any of the great list above. If EHR certification of any kind (CCHIT or otherwise) could somehow assure: a higher implementation success rate, a better level of patient care, a higher quality user experience, a financial benefit, or any other number of quality benefits, then I’d support it wholeheartedly. The problem is that it doesn’t, and so they can’t make that assurance.

So, yes, I do take issue with an EHR certification which misleads doctors. Even if it’s the EHR salespeople that do the misleading.

I still remember the kickback I got on this post I did where I said CCHIT Was Marginalized and the post a bit later where I said that the CCHIT process was irrelevant. Today, I came across an article on CMIO with some interesting quotes from CCHIT Chair, Karen Bell. Here’s a quote from that article.

In addition, the Office of the National Coordinator for Health IT’s (ONC) new program has provided two new reasons for certification: proof that an EHR can do the things that the government wants it to do, and to enable eligible providers and hospitals to get EHR incentive money.

“The idea is not to assure the product will do all things that are desired for patient care, instead, the idea is to stimulate innovation,” said Bell. As a result, the program is considered a major success because more than 700 certified health IT products are now on the ONC website. “The idea was to get a lot of new products started. This is a very different reason for certification than what we began doing several years ago,” she said.

However, just because CCHIT or another ONC-Authorized Testing and Certification Body (ONC-ATCB) doesn’t test and certify for a particular ability, that doesn’t mean the EHRs don’t have it. “It’s just up to [the provider] to make sure the vendors have it,” said Bell.

I first want to applaud Karen Bell and CCHIT for finally describing the true description of what EHR provides a clinic assurance that:
1. The EHR does what the government wants
2. You are eligible for the EHR incentive money
Then, she even goes on to say that it’s up to the providers to make sure the vendors have the right capabilities for their clinic.

I imagine Karen and CCHIT would still probably say that the CCHIT “complete” EHR certification provides assurance that…< fill in the blank >, which the ONC-ATCB EHR certification doesn’t provide. The happy part for me is that even if CCHIT says this, no one is really listening to that message anymore.

Yes, CCHIT has essentially become irrelevant.

I can’t remember anyone in the past year asking me about CCHIT certification. From my experience, many people care about ONC-ATCB EHR certification, but they really couldn’t care less if it comes from CCHIT, Drummond Group, ICSA Labs, SLI Global, or InfoGuard (That’s all of them right?). Have any of you had other experiences?

I also do enjoy the irony of this post coming right after my post about differentiation of EMR companies (Jabba vs Han Solo). CCHIT is the reason that I know so much about the challenge of EHR differentiation. CCHIT’s efforts provided some very valuable (and lengthy) discussions over the past 5 years about ways to help doctors differentiate between the 300+ EHR vendors. As you can see from my comments above, I was just never satisfied with CCHIT being the differentiating factor. As you can see from my post yesterday, I’m still searching for a satisfactory alternative for differentiating EHRs. Until then, we’ll keep providing an independent voice a midst all the noise.

In a previous post, Anthony made this basically off the cuff comment which hit me:
“many a time, the functional requirements take priority over UI”

We see this all over the software development world. In fact, it takes a really unique company to be willing to keep UI over functionality. Ask any salesperson and they’ll tell you that new functions are easier to sell than a great UI. So, it makes sense why this happens. Unfortunate, but makes some sense.

However, this comment also had me asking myself the question, “I wonder how many meaningful use and/or EHR certification requirements caused issues with an EMR UI?”

I’ve already had a few EMR demos where I said, what’s that button/function doing there. The response was, oh that was to meet meaningful use/EHR certification requirements. I’m sure many other doctors that use an EMR have seen the same thing. They wonder why an EMR has certain functions since they don’t provide better patient care. Certainly meaningful use and EHR certification is likely to blame for a lot of these possible UI issues. However, I’m sure that many more have to do with EMR software vendors that want to be all things to everyone. When you go down that path, it’s hard to maintain a great UI.

I’ve been starting to think more and more about various EMR UI. Especially with the recent launch of an EMR screenshots website. I’m grateful for the EMR vendors that have been great about sending over their screenshots. It provides an interesting view into the various EMR UI’s. I’m hoping to do some future posts where I take one or more of the screenshots and analyze some of the details. We’ll see how well that goes with an EMR screenshot.

One of my favorite EMR people, Matt Chase from Medtuity, wrote this interesting comment over on EMR Update.

Times are achanging. I think a recent install is a good example. The group purchased a decently well-known EMR and it failed. So they went with a second well-known EMR and it failed. Both were certified. Both had a very active sales team. The second one flew in some upper level sales people from the coast when there was talk of deinstall.

After spending half of the national debt and a looming closure of the practice, they called in a consultant. He made his recommendation. They did their demo and they asked the really hard questions– show me how to create new clinical content, show me how to create a new template, edit an existing one, how to fax a single encounter to another practitioner, then multiple encounters but not all encounters of a patient, track any lab value over time, send a reminder to a staff member, assign faxes and scans, etc, etc. Their list was very long. They did not want to hear promises and they did not want a canned demo. They wanted to see the software perform the steps that were lacking (but promised present) in their previous software.

The underlying theme here is that practices believe that certification is truly a functional seal of approval. It is not. Secondly, because certification exists and so many EMRs (>450) are certified, it implies a mature product offering– like buying a hard drive or a computer. You can expect certain functionality to be present simply because the maturity of the market would have eliminated the company. Unfortunately, just the opposite is true.
…
Just this week I learned that a very large practice in our town is out shopping another EMR. Yes, they have a certified one, but they certainly aren’t paperless.

Functionality will become the watchword of EMR, not certification.

That’s some interesting projections. I remember one EMR vendor telling me that a large portion of their sales were to existing EMR users. In fact, I think they said that there favorite implementations were existing users that were switching to their EMR. I also love the observation of how much better an organization is at selecting an EMR the second time they do it.

Chris asked the following question:
Do modular certified EMR’s qualify for meaningful use and also qualify for full incentive payouts?

Answer:
Modular certified EHR software can qualify for meaningful use and the EHR incentive payouts. Although, they can’t do it on their own. Although, if you combine the modular certified EHR with other modular or full certified EHR software, then you can qualify. Clear as mud huh?

The good thing is that you can go to the ONC CHPL website and select the certified EHR software which you use and it will tell you if combined it meets the criteria.

So, for example, maybe you have a modularly certified EHR that is certified for everything but ePrescribing. You could then also purchase a certified ePrescribing software and together they would be considered a complete certified EHR that would qualify you for the EHR incentive money.

At least this is my understanding of the intent. I’m sure there are going to be lots of little intricacies without clear answers.

UPDATE: There was some discussion in the comments about whether you had to have a complete EHR or only one that had the modules you use to show meaningful use. Thanks to Jim Tate for finding the HHS reference that says you do have to have a complete EHR even for the modules which you’ve excluded or menu set objectives which you didn’t select.