I must admit that I’m so happy to be home from HIMSS. It was a fantastic couple of days, but it’s always nice to be at home. Not to mention, posts are so much more fun on a regular keyboard with 2 monitors. Of course, my email box is full of the notes that I took during the various interviews I did at HIMSS. So, you can expect a lot more posts talking about the things I learned and saw at HIMSS. Not to mention a video series of innovative and interesting products at HIMSS (Sponsored by Practice Fusion).

For my first post after HIMSS, I decided that I couldn’t help but post about the CCHIT town hall at HIMSS. I really said a lot of what I thought on my twitter account, but I’m sure that many missed it. So here’s a short summary of my thoughts with some other commentary on Mark Leavitt’s swan song at HIMSS.

The first thing that bothered me most is what has bothered me about CCHIT for a long time. However, this time I could document first hand the things that CCHIT was saying that was confusing doctors about what the CCHIT EHR certification was all about. Here’s what I recorded them saying (usually on their powerpoint too) that really doesn’t tell the whole story:
“Maximal assurance of comprehensive, integrated EHR capabilities”
Maximal assurance of what? That the EHR is comprehensive? No doubt doctors will see this as saying that a certified EHR will have all of the EHR features that they need. However, how does CCHIT know that it will have all the features all of the various types of practices need? Of course they don’t. They would even admit that it doesn’t. It just is able to run their test scripts based on a list of requirements. That’s where they confuse doctors.

“EHR with all necessary functionality”
and
“Everything you need in an EHR if you do the comprehensive certification.”
Same principle as the previous comment. How can they know what’s necessary? They don’t.

As I sat there listening to this, I wondered if I should get up and ask them a question. I wasn’t sure that me asking a question would be of any value. Then, I decided that I should at least try and help those in the audience to understand the real benefits (or lack thereof) of CCHIT certification. So, I got up and asked the following question (more or less):

What type of assurance does CCHIT offer to doctors? Does it offer better patient care? Are certified EHR more likely to be implemented successfully? What assurance can you offer beyond just talking about the process you went through to create the criteria?

They both (Mark Leavitt and Alisa Ray) kind of looked like they didn’t quite understand the comment. However, Mark basically responded that CCHIT doesn’t make any guarantee of increasing successful EMR implementations or improve patient care. He said that he didn’t think anyone could make that guarantee. CCHIT assures doctors that it meets the criteria that has been created.

Many people wonder what I have against CCHIT. I actually don’t really have any real ties to CCHIT (see my previous post). It just really bothers me when doctors get the wrong impression based on a miscommunication. I don’t like it when EMR salespeople confuse doctors through EMR sales miscommunications and I don’t like when doctors don’t understand what they’re really getting from a certified EHR.

The real problem is that even writing this post, far too few people will get the real message about the benefits (or lack thereof) that are provided by CCHIT certification. Although, I was pleased by all the people I’d never met before stopped me around the conference and told me that I asked a very important question at the CCHIT town hall.

Enough of that for now. Here’s some of the other items that I tweeted about CCHIT (some additional comments in italics):
CCHIT to certify Oncology and Women’s health(Obstetrics and Gyn). Will doctors care? EMR vendors might.

CCHIT had 23 comprehensive and 23 modular EMR cert applications.
46 brave EMR vendors. Although, I think this number is a little misleading. I talked to one of the EHR vendors that has the comprehensive certification and they said that there are only 2 that really have the comprehensive EHR certification. All the rest are “provisional.” I didn’t check those facts, but that says something if indeed it’s true.

CCHIT has announced site certification, but we don’t yet know if HHS will recognize an EHR site certification, no?
After the ONC town hall we now know that ONC will be fine with this as a secondary method of certification if the EHR certifying bodies see it as appropriate.

Nice to see that Mark Leavitt’s recommendations all use CCHIT products. I have a few other options people might consider that don’t.
Mark also referred to not going after a certification to be like gambling. Coming from Vegas I’m not sure I like his gambling reference. However, I really do think there are other options to CCHIT certification. Drummond Group and a third one I learned of at HIMSS which I’ll be writing about shortly too. Although, it certainly makes sense why Mike wouldn’t have acknowledged the other bodies. Although, isn’t CCHIT a non profit? Shouldn’t they just want the best interest of the industry?

With the government program we don’t create the criteria anymore. -Mark Leavitt of CCHIT

CCHIT site certification will be hospitals first. Ambulatory site EHR certification later?
Makes sense that CCHIT would go where the money is, but not a happy thing for the small doctors offices.

“We’re doing EMR usability at a kindergarten level and some EMR vendors don’t pass that.” -Mark Leavitt
This is a really sad fact. It’s nice of Mark to acknowledge it. One other person I talked to at HIMSS suggested to me that CCHIT shouldn’t be doing EMR usability testing at all. However, I’m really not sure what it says about an EMR that can’t pass the simple usability tests that CCHIT does do.

I’m always amazed at how little connection CCHIT has with ONC/HHS. Seems like a telling thing that they don’t.

FierceEMR has really hit the healthcare IT arena in force over the past 6 months. They even have a big party planned for HIMSS. I’ll probably be stopping by since it’s the day after the New Media Meetup at HIMSS. Well, one of my favorite healthcare IT writers, Neil Versel wrote an article for FierceEMR that really caught my eye. It was titled, “Kibbe: New ONC standards make CCHIT process ‘irrelevant’”

If you’ve read this blog for any time you know that I’m an enormous fan of CCHIT (that was in the sarcasm font in case you couldn’t tell). I even declared the Marginalization of CCHIT back in July of last year. So, obviously I agree with David Kibbe’s assertion that the CCHIT process is irrelevant thanks to the HITECH act. A section of the article linked above describes some of the major problems with CCHIT:

Kibbe long has said the CCHIT certification process discourages innovation by being too complicated and costly for new, small companies that otherwise might shake up the EHR market with lower-priced, easier-to-use products. He also has held that the certification body was too closely tied to the health IT establishment. “CCHIT in effect acted as judge and jury for its own industry’s definition of EHR software, inhibiting alternative approaches that would embrace component or modular architectures, web-based delivery also known as ’software-as-a-service,’ and practical means of achieving interoperable data exchange between applications from different vendors,” he says in a recent blog post.

No doubt the CCHIT criteria is no longer meaningful. The only problem is that a question still haunts my mind, “Did we just move the flawed process from CCHIT to ONC?”

We’ve had a lot of discussion in the past about the cost of EHR certification. It’s been one of the biggest complaints about CCHIT and their EHR certification. One of my readers wanted me to post again about the costs and how this will be such a challenge for new EHR vendors.

First, the problem isn’t that a new EHR vendor couldn’t afford the cost if they wanted to pay it. The problem is that it provides very little benefit to the end users and at the end of the day the cost of the EHR certification would be passed on to the doctors who purchase the EHR.

I’m going to use round numbers, but you can see the detailed CCHIT EHR certification costs on my previous post. Basically as it stands today, full CCHIT EHR certification will run a vendor $37k or more to become certified. Of course, if you just want to be Preliminary ARRA Certified (although we don’t even know if that’s true yet either), then it’s only $33k. Yes, you can certify fewer modules, but that won’t make much sense for most EMR vendors.

Yep, that’s right. $33k that an EMR vendor will have to pay for certification which will add little value to end users and decent marketing value for the EMR vendor.

Of course, this doesn’t take into account the development costs to meet the standards (which I should remind you are still not finalized). I read one EMR vendor say that to become CCHIT certified (this was back in 2006 or so) it cost in the six figure range. That’s a lot of money for what?

We know that the Drummond Group and possibly other organizations are planning to certify EHR as well. In fact, the Drummond Group just launched an EHR Certification blog. In the first comment on their blog, they got a question about how much they’re planning to charge for EHR certification.

I’m sure that these organizations will try to undercut CCHIT as far as EHR certification pricing. I’m just not sure it will be enough to make much difference. Why would they undercut them too much?

One of my favorite bloggers, Will Weider, had a nice idea with a post called “All I Want for Christmas is ARRA Answers.” I liked the idea so much that I decided to take it and post my own questions. Plus, some of his focus on hospitals which don’t interest me as much as ambulatory. So, here are the questions I’m hoping David Blumenthal and company can provide us for Christmas.

1. What’s the HHS EHR certification criteria? Will it be a complex set of criteria with little value (see CCHIT) or will it be a streamlined version that encourages EHR adoption? Especially interesting will be comparing the HHS criteria with the CCHIT preliminary ARRA certification.

2. How will HHS define “meaningful use?” Will they follow the meaningful use matrix as proposed by the HIT Policy and Standards Committees or will they take pieces here and there?

3. Regardless of what HHS defines as “meaningful use,” how does HHS plan on measuring and ensuring meaningful use of an EHR? This will be interesting to see if HHS comes out with a plan that is scalable and difficult to game. Definitely a challenging job to ensure it’s meaningfully done. (I want to see how many times I can write the word meaningful).

4. How will the various meaningful use and certification criteria apply to specialties? Will they come out with a spectrum of meaningful use guidelines for various specialties? Will they create exemptions for certain specialties? or Will they just be vague and provide no guidance for specialties, essentially leaving them with a guessing game?

5. What will be the timeline for ARRA EHR stimulus money? Will it be paid out quarterly based on the most recent quarter or past quarters. Will you have to have ongoing proof of meaningful use quarterly or annually?

6. What will be the process for recognizing new EHR certification bodies? Will they create some barriers that only allow CCHIT to certify EHR? Will other companies like the Drummond Group really join the fray?

I’m sure there are many more. What questions are you hoping to get answered for Christmas? Although, let’s be honest. I think we’re more likely to get a New Years gift of answers than we are a Christmas one.

I’ve get all sorts of interesting emails sent to me because of this site. Many people send me questions and as much as I can I try to answer them. In fact, it’s usually quite fun if I have the time. This time someone sent a couple interesting questions about the EMR stimulus money and their practice which already uses a non CCHIT EMR. I thought the 2 questions she asked might be of interest to other readers of this site and so I’ve copied the EMR stimulus questions and answer below.

Our medical practice has been using a non CCHIT EMR software prior to the stimulus plan. Can my doctors still qualify for the incentive?
Absolutely!! CCHIT certification does NOT matter anymore for EMR stimulus money. Instead what matters is that the EMR is HHS Certified (or whatever name HHS comes up with for their EHR certification criteria). There will be a number of EHR certification bodies (likely including CCHIT) that will be prepared to certify your EMR against whatever criteria is put together by HHS (although technically I think it’s CMS that does this dirty work). They have a deadline of the end of the year to put out the details of what the criteria will involve.

Also, there has been some discussion of the possibility of an EHR “site certification” Basically, even if your EMR software chooses not to become certified, you could possibly get your “site” EHR certified. It’s too early to see exactly how this part of it will play out, but it’s been proposed and I think is likely to happen.

Also, how will Medicare know whether or not a practice is using an EMR software if they are already billing electronically?
This is a good question for which we don’t know the entire answer. Hopefully when HHS releases the definition of what constitutes “meaningful use” (the other key word to get the EMR stimulus money) by the end of the year, we’ll have a better idea of how they’ll measure “meaningful use” in a clinic. My best guess is that it will include some set of reporting and possibly some demonstration of interoperability, but who knows what else they’ll come up with to measure it. Hopefully they’ll keep it as unobtrusive and meaningful as possible. However, this is government work.

Unfortunately, it’s still a bit of wait and see. The good news is that you might actually be in a better position than those that haven’t yet implemented an EMR.

I’ve had real problems with the idea of there only being one EHR certifying body for a while now. I think competition usually brings the best out of organizations and forces them to be better than they would have been had there been no competition. Plus, it usually brings the price of things down also.

With that background, I was very happy to see that Drummond Group Plans to Certify EHR software as well. One of the comments on this blog pointed this group out to me and I’m very happy to see that they’re planning to enter the EHR Certification fray. Here’s a short quote from their press release:

Drummond Group has been approached recently by numerous EHR software and services companies that need to be certified.

“Clearly there is a growing demand for EHR certifications, says Rik Drummond, CEO of Drummond Group. “Drummond Group has been supporting Fortune 500 industries and government by certifying the transfer, identity and cybersecurity of their internet information flow over the last ten years. We have also done testing for the CDC, DEA and GSA. Certification of EHR is a natural extension of our testing program, and we believe we can provide great value for the medical community. We look forward to the publishing of the ONC requirements in the days ahead so we can get started.”

This is very good news!

I contacted Drummond Group to try and get an idea of how much the Drummond Group EHR certification might cost. As expected, there answer was that they’d be waiting for the ONC certification criteria before determining the cost and “what” to certify. So, we’ll have to wait to compare Drummond’s EHR certification costs with CCHIT’s EHR certification costs.

I also asked them whether they thought they would continue EHR certification after the EHR stimulus money runs out. Here was their quick response:

We would plan to continue if the users were happy with the certification after the stimulus money is gone…we have tested one standard for over 9 years without stimulus funds. In that case, the users still find great value in certified interoperable products and the numbers continue to grow in adoption. The vendors view Interoperability Certification as two things:
The certification seal adds marketing recognition and the testing is considered an extension of their
own Quality Assurance testing that they could not create internally on their own. It’s a win-win.

If they do decide to continue certifying EHR, I hope they will focus on interoperability certification. That could be beneficial and what I think the EHR stimulus money should have been spent on in the first place.

Every couple posts I have to write about CCHIT or EHR certification. It’s one of my favorite topics to write about, and I believe it’s one of my readers favorite topics as well (at least that’s what traffic tells me).

Today I want to take a look at what I believe is a new addition to the CCHIT 2011 EHR Certification. At least I hadn’t heard of it before. This is what CCHIT is calling Reference Site Verfications. From what I can gather they’re basically planning to verify that there are 2 live sites that have been using the certified EHR for at least 45 calendar days. For those new EMR, they can be certified with what CCHIT is calling “Pre-Market” status, but the EMR vendor must have 2 approved sites within 1 year of when they were initially certified. I also like that CCHIT is requiring that the 2 approved sites have no financial relationships with the EMR vendor. However, I’m not sure how they’re going to know if this is the case or not.

The questions I have is how they’re going to know and test that the 2 reference sites are using the EMR. According to CCHIT guidelines these EMR sites must be actively using key Meaningful Use components:
Ambulatory: ePrescribing, Drug decision support, Electronic receipt of labs, Problem list, Quality reporting
Inpatient: CPOE for medications, Drug decision support, Electronic receipt of labs, Problem list, Quality reporting

I admit that I love the concept of verifying that the software’s actually being used as it should be being used. My challenge is I haven’t figured out how CCHIT can do this effectively across so many different systems and locations. I know Sue from CCHIT has read some of my previous posts, so hopefully she can respond in the comments and give us more details.

CCHIT has also planned an annual monitoring of the certified EHR systems. Basically a look at one of the previous reference sites and a new site.

I find this reference site plan by CCHIT to be very interesting. I like that they’re trying to find places that actually use the EMR and they use the full set of features of the EMR as well. However, I’m not sure how well they’ll be able to measure this effectively and even if they could I wonder if 2 locations is enough to provide a valuable measure.

Of course, I should also clarify that this is just for the CCHIT 2011 certification and not the certification that CCHIT will be doing for those interested in the ARRA EMR stimulus money. At least that’s my understanding.

No one asked (well at least not publicly), but I wanted to share my opinions on what EMR vendors should be doing in regards to EHR certification. I guess you could say this is a small sample of the advice I’d offer as an EMR vendor advisor albeit not EMR vendor specific and with less detail. Take it for what it’s worth.

If I’m an EMR vendor today, I’d definitely avoid going out and getting either the CCHIT Certified 2011 or the Preliminary ARRA 2011 EHR certifications. One reader of this site emailed me an estimate of $100,000 up front and $9,000 renewal fee per year for the CCHIT certifications they were considering. Certainly it could be less if you just go with the Preliminary ARRA certification, but regardless the cost is quite large.

Instead, I’d take a more reasoned approach. There are 2 important things for an EMR vendor to consider when it comes to EHR certification.

1. EMR vendors need to be able to sell product and allay customers concerns about your EMR not being certified. Many people will be asking for EHR certification and even more people will be asking for the EHR stimulus money.
2. EMR vendors want to make sure that they’re well positioned to become HHS certified (at least most of them) once HHS pulls back the curtain and shows us what that will be. However, they don’t want to waste development dollars on features that don’t improve their product.

With these two considerations in mind, my suggestion is for EHR vendors to take a look at the Preliminary ARRA Certification (in particular the Meaningful Use Matrix Tagged for CCHIT Reference document (pdf) is a good start). Take the list of criteria that CCHIT has created and matched up with the meaningful use matrix. Then, evaluate the criteria to see which ones you don’t have and would be of value to your customers. Next, prioritize that list and add those criteria that add value to your EHR development plans.

The concept is simple. Despite my ripping on CCHIT, there are certain aspects of their criteria which are incredibly valuable to a doctors office. Take those criteria that will provide value to your EHR end users and spend your development time adding value to your product. Then, once HHS/ONC/CMS publishes the final criteria for achieving EHR certification you will have hopefully already developed a number of the criteria while not wasting time developing CCHIT criteria which won’t be required by HHS/ONC/CMS. Once we know what the real EHR certification criteria is going to be, you can decide which “certified EHR” option is best going forward.

There is one caveat to this suggestion. You’re going to have to be able to tell a compelling story to some clinics about why you aren’t doing CCHIT certification. However, from what I’ve heard from other EHR vendors and my experience talking to people, it’s not a huge hurdle to explain how you’re going to get them access to the EHR stimulus money and how CCHIT certification would have increased the cost of your EHR product while not improving the life of the doctor. Let them know that you evaluated the CCHIT criteria list and implemented those of value. Then, list one CCHIT criteria that doesn’t add value and they should see pretty clearly why you made a good choice.

What do people think of this advice? Does it make sense? Is there something else I’m missing?

John Halamka recently posted the following about whether doctors and practices should wait to purchase an EMR. Here’s his response:

I’m often asked by clinicians and hospitals if they should wait to purchase an EHR because of the uncertainty regarding meaningful use and certification.

I tell them to move forward now.

The following is my response I made to him in the comments of his blog:

Thanks for sharing the timeline[also included in the blog post listed above and similar to my previous post on the EMR stimulus meaningful use and certified EHR timeline]. However, I do disagree with you that people should be selecting and implementing an EHR now. There’s no rush to do this. I can agree that users should start reviewing the various EHR vendors and technologies that are available so that they are familiar with the choices that exist. However, it’s premature for those users to actually select and implement an EHR.

Your suggestion of choosing a CCHIT certified EHR is also off base. The fact is that not even the onerous CCHIT certification criteria meets the meaningful use matrix that you reference. So, the certification criteria will change and it’s likely that not all CCHIT certified EHR will achieve HHS EHR certification (which is what really matters for the $$).

Instead, the wisest counsel that can be given to providers is to select an EHR based on which EHR software will best meet their business needs. If they do that, then whether they’re able to get the EHR stimulus money or not they’ll be happy with the decision they make. The EHR stimulus money will just be a nice bonus if it all works out well.

What do you guys think? Is the time now to purchase an EMR?

In my last post Michael Milne made the following comment that I think was worth discussing:

I firmly believe that less than 5% of all doctors who do buy a “certified” EMR are going to collect.
…
For example, how many here, or even heard of someone, have actually collected the e-prescribing incentive?

I think that 5% is a low estimate of who will collect on the EMR stimulus money. Although not that much lower. What do you think?