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.
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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.

If you’ve been following this blog for a while, then you probably remember my many rants about the lack of value in EHR certification. In fact, Jim Tate asked me at HIMSS where my dislike of CCHIT came from. I think I told him that I probably got it from EMRUpdate. Certainly that’s where I learned a lot about EMR and EHR and certification in general. However, as I consider his question, my real distaste with CCHIT and quite frankly EHR certification is that it provides little to no value to doctors.

Looking back at all the discussions I had last week with those attending HIMSS, I’m really happy to say that EHR certification was almost never a discussion. Pretty much everyone either was a certified EHR or was almost done with the EHR certification process (which is in line with ONC’s desire that all EHR software be certified).

I still feel that certification provides little value, but I’m really happy to see that EHR certification has basically left the discussion. If everyone has it, then doctors don’t and won’t look to it as a way to select an EHR. I think that’s a very good thing.

As I’ve thought more about EHR certification, it’s funny that someone hasn’t come out with some healthcare IT certifications that would actually provide value to doctors and healthcare. Here’s just a few ideas off the top of my head of items that could be meaningfully certified:

• Privacy
• Security
• Data portability
• Freedom of data
• SaaS hosting services

The interesting thing is that many of these certifications could be provided well beyond EMR software and into other healthcare IT products (and even beyond if someone so desired). Certainly the existing EHR certifications try and provides some of these items, but they’re so general and non specific that they aren’t very useful.

For example, the privacy certification could include not only that the data is encrypted but could specify which type and level of encryption is used. Plus, the certification could actually test the encryption to make sure it was implemented properly. I know some eFax vendors that would love this type of certification.

A certification that provides value wouldn’t likely be a simple pass fail certification. Maybe you do set a bar for each requirement that allows you to place a certification badge on that product. However, users should be able to dig into the details of the certification and see what was found during the process. For example, if you make sure they handle passwords correctly, a certification should provide a list of protections that are built into the software that’s being certified (ie. minimum characters, required characters, 2 factor authentication, number of failed passwords before lockout, etc).

If I weren’t so busy with my healthcare IT blog network, I’d consider doing some of this myself. Not only is it a great business, but could really provide value to healthcare. If you start it, just save me a spot as an advisor.

In probably the biggest news of the day at HIMSS, we got the following tweet spreading quickly through the Twittersphere:

RT @afbmet Chuck Friedman from #ONC just announced that “usability WILL be in Stage 2 of #meaningfuluse at the #Usability Symposium #himss11

February 20, 2011 9:23 am via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

There you have it. Word out of ONC is that meaningful use stage 2 will include some form of EHR usability. How that will be, I don’t think even ONC knows. Although, I’m sure they’ll consider looking at the EHR usability that’s already in CCHIT.

What I don’t understand is why they would do this. First, it should be part of the EHR certification and not meaningful use (maybe it was a mistweet). Why would ONC want to measure an EHR’s usability during meaningful use? That’s too late, no? Although, maybe it’s just ONC trying to collect data for other doctors that will select an EHR later? I don’t understand it.

Plus, let’s look at the EHR usability that’s been done by CCHIT. Has it really improved the usability of EHR systems?

I asked someone at HIMSS this question, and they said something like, “Of course not.”

We all want the EHR software to be usable. I just don’t understand how ONC adding it to meaningful use stage 2 will help achieve that goal.

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

The other day I came across an interview with David Blumenthal. I didn’t find anything all that meaningful in the interview itself. However, in the comments, someone provided some really interesting commentary on what Blumenthal said in the interview.

Dr. Blumenthal says we need operability before we move to interoperability. Yet if you don’t design your systems from the start to interoperate, you’ll inevitably wind up with operable systems that do not interoperate – at all. Having accomplished this, we’ll then have to develop and impose an after-the-fact standard to which all systems must comply. This will mean redesign, retrofit, and plastering all kinds of middleware layers between disparate systems. It may even result in retraining tomorrow all those providers you hope will learn new ways of working today.

Dr. Blumenthal also says that new and better technology is coming out every day. Yet the current incentive and certification programs heavily favor the older technology which he himself says frightens many providers away from this migration. Many of the older vendors have huge installed bases and old technology. They no doubt influence advisory boards much to lean towards what is versus what might be, all assurances to the contrary.

The cost of fixing practically anything is much higher than doing it correctly the first time. I realize you can’t design perfection, and anything we build will need adaptation and improvement. But we’re following a path that ensures that we will have to do much more fixing than we would if we’d just stop and think a bit more.

The inevitability of this evolution is not a justifcation for doing it carelessly.

Talk about bringing up some valid issues. The second one really hits me that the incentive money favors older technology. I’m afraid this is very much the case and that 5 years from now the major topic we’re covering on EMR and HIPAA is switching EMRs.

The always opinionated Anthony Guerra has an article up on Information Week that describes why he thinks the Meaningful Use sky is falling. Add that to a recent comment I got on a previous post that links to a Healthcare Data Management article talking about the potential repeal of the HITECH act and it seems worthwhile to assess the state of meaningful use.

I’ll start with the potential repeal of meaningful use first. We’ve known for a long time that the house was going to be going after healthcare reform once the republicans took over control of the house. In fact, we posted about the potential impacts to HITECH from the new Congress before.

I personally get the feeling that not much has changed on this front. I’m going to reach out to some of the government liasons for EHR vendors that I know that follow this even closer than I do. However, I still believe that:
1. The HITECH funding or at least the Medicare and Medicaid stimulus funding is safe from Congress. I’ve read this a couple of places and so I believe it to be true.
2. Any legislation that is passed by the house still has to pass through the democratic controlled Congress and avoid the Presidential veto. These two seem unlikely.

Of course, when it’s government work you could always be surprised by some loophole in the process that impacts funding or legislation. I won’t be surprised if one of these loop holes appears and affects the HITECH act. However, I still argue that if something does happen to HITECH, it will likely be a casualty of some other political agenda (ie. cutting whatever costs they can find) and not actually because they were specifically targeting HITECH.

Long story short: I still feel like the EHR incentive portion of HITECH is likely safe. Maybe some of the other funding will be cut short. We’ll see.

Now to the points that Anthony Guerra makes in his article. He describes the challenges that many hospitals are facing in regards to meaningful use. Plus he highlights the potential difference in the number of people who “think they qualify for the money” and those who “plan to apply.”

I might argue that if EHR adoption is the goal, then this might not be such a bad result. The idea of “forcing” meaningful use on people has always bothered me a little bit. Encouraging people to show meaningful use is only as good as the meaningful use criteria. If the meaningful use criteria is not very good, then do we really want everyone showing meaningful use?

For example, imagine that a doctor or hospital decides to use an EHR based on the EHR software’s ability to improve the efficiency of their office and the quality of the services they provide to the patient, but deems meaningful use as contrary to those goals. This seems like a great outcome to me. In fact, it seems like a better outcome than a doctor trying to force themselves into the meaningful use hole.

Obviously there are parts of meaningful use that can be very beneficial. For example, having an EMR that can communicate using a standard format (CCD for example) is important and valuable. If it is beneficial, then I see most doctors implementing these features regardless of whether they showed meaningful use or not.

One thing definitely seems clear from all the surveys and other stats I have: interest in EMR has never been higher. Whether that translates to “meaningful use” of a “certified EHR” or physicians meaningfully using an EHR of their choice, is fine with me.

You know my mantra: Select and implement an EMR based on the benefits that you and your clinic want to receive from the EMR. Don’t select and implement it based on a government handout. Those hand outs will be gone after a few years, but your EMR will be with you long after.

Looks like the people at HHS and ONC have been working hard. On Monday this week they published the Permanent EHR Certification Program Final rule. You can find the press release about the Permanent EHR Certification final rule on my new EMR News website (if you have other EMR news, please let me know).

You can download the full Permanent EHR Certification final rule here (Warning: PDF). Although, I must admit that I found the permanent certification fact sheet very interesting. Here’s my summary:
*Testing and certification is expected to begin under the permanent certification program on January 1, 2012 (with an exception if it’s not ready)
*NIST (through its NVLAP) will continue with accrediting organization to test EHR and to work with ONC to create test tools and procedures
*A new ONC-Approved Accreditor of ONC-AA will be chosen every 3 years
*All ONC-ATCB (those bodies certified under the temporary) must apply to be ONC-ATB (permanent certification bodies)
*ONC-ACB have to renew every 3 years
*Gap Certification will be available for future EHR certification criteria.

The most interesting part to me was that ONC will be selecting an ONC-AA (Approved Accreditor) through a competitive bid process. So, they’re going to accredit an accreditor to accredit the certifiers? I think you get the gist. I can see how ONC saves so much by only having to have to deal with one ONC-AA and not the 6 ONC-ATCB (that was in the sarcasm font if you couldn’t tell).

It does make sense to have a gap certification so that EMR vendors that are already certified don’t have to certify against all the criteria every time. I guess in theory changes an EHR vendor has made could have caused issues with their previous functions, but that’s pretty rare. Especially since their users will need it to be able to show meaningful use (which is why EHR certification has little meaning beyond it being required for EHR incentive money).

Whether you agree or disagree with EHR certification (I think you know where I stand), you have to give ONC credit for pushing out the EHR certification program so that there are plenty of certified EHR software out there to choose from. Looks like they’re well on their way to implementing the permanent EHR certification as well.

Pamela sent me the following EMR stimulus question in response to my post about Doctor’s having no choice with meaningful use:

Can we show meaningful use without a certified EMR or would we still be penalized since our EMR vendor has no intention on becoming certified?

The current HITECH law requires meaningful use of a certified EHR. So, you have to use a certified EHR to get the EMR stimulus money and to avoid the Medicare penalties. They have been looking at doing site certifications so you could show that you’ve put together everything to satisfy the certified EHR portion. However, so far I’ve only seen the site certification really apply to hospitals. I haven’t seen a site certification for smaller doctors offices (yet?).

Just be aware that some are suggesting that the penalties will never be imposed. Basically, they say that ONC will just keep delaying those penalties for one reason or another and that they’ll never actually be enforced. Plus, don’t be surprised if they make exceptions for certain medical specialties. For example, if not a single chiropractor (or some small number) shows meaningful use of a certified EHR, then it seems reasonable that ONC could look at making an exception for those specialty groups.

It’s also worth taking a look at this post I did which gave an example of the EMR stimulus Medicare penalties. They don’t amount to as much as you’d think.

I imagine we’ll see quite a few faced with this situation. This will become even bigger when some EMR vendors decide to deal with meaningful use stage 1, but choose not to prepare for meaningful use stage 2. Allscripts will be doing this with their now sunsetted EMR acquisition, Peak Practice. Basically, they’re going to make it work for meaningful use stage 1, but then users will have to switch to a different Allscripts EMR for meaningful use stage 2. That will make for a tough decision for someone who has to switch EMR software to get more stimulus money and avoid the penalties.

I have a strong feeling that EMR and HIPAA is going to make a switch from talking about selecting and implementing EMR to switching EMR software over the next 5 or so years. Not a fun subject for providers to consider, but many are actually doing it now.

In a move that we’ve heard talked about for a long time now, CCHIT has finally announced its site specific EHR certification. This is the EHR certification that hospitals that have built their EHR software in house should consider.

The Certification Commission announced today a new electronic health record (EHR) certification program for hospitals that will be introduced at a Town Call webcast and teleconference Dec.1, 2010, and launched Dec. 15, 2010.  The EHR Alternative Certification for Hospitals, or EACH™ program, an ONC-ATCB 2011/2012 certification for installed hospital EHR technology, is designed to meet the needs of hospitals that have uncertified legacy software, customized commercial  products, or have developed their own EHR systems to suit their individual needs.  The teleconference will take place at 1 p.m. Eastern. Call-in details are available at cchit.org/towncalls.

“Until now, CCHIT’s ONC-ATCB certification was available only for health IT vendor developed products. Our new certification program is an alternative for hospitals that have developed their systems with products that are not individually certified or are a mix of certified and uncertified products.   These hospital EHR systems are often very sophisticated and may have been developed over many years.  Yet, they must be certified for hospitals to qualify for financial incentives through the American Recovery and Reinvestment Act (ARRA), and avoid Medicare penalties,” said Alisa Ray, executive director, CCHIT.
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Alternative certification is not needed if a hospital has adopted an EHR with complete certification, or a combination of certified EHR modules that meet all of the 2011/2012 certification criteria adopted by the Secretary of Health and Human Services to support the meaningful use objectives established by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services (HHS).

Unfortunately, there was no talk of price in the press release from CCHIT. Looks like we’ll have to check out the Town Hall to see how much the EHR site certification (now called EACH by CCHIT) is going to cost. I imagine it won’t be that much less expensive than the current full EHR certification. Seems like the requirement list should be the same no?