In a recent discussion I had, someone brought up a really interesting question about module certification to me. Obviously, proving that you use a certified EHR is quite easy if you just use one EHR software that’s a complete certified EHR based on the ARRA guidelines. Then, you can fitfully say that you use a certified EHR.

Even this isn’t that confusing if you use one complete EHR software for everything, but say ePrescribing. Of course, the ePrescribing vendor would need to be certified for those modules, but you can easily show that both are certified EHR and you use all the modules.

The questions start coming in when you start to talk about module EHR certification when you just purchase parts of a software. Let’s say you purchase only part of a certified EHR software (ie. no ePrescribing and no Patient Portal). You don’t purchase those 2 modules since you already use other software to match those needs and their certified for those modules.

The problem with this scenario is how do we know that the main EHR software that you purchased has all of the certified EHR functions if you never purchased two major components? How do we know that the ePrescribing component actually also did some other part of the EHR certification that wasn’t part of the ePrescribing module certification?

Of course, you could easily argue that it doesn’t really matter because if you’re able to show meaningful use with what you bought, then does it matter if your combined EHR software with the other modules wouldn’t technically have passed an EHR certification? It absolutely doesn’t matter. In fact, that’s exactly why EHR certification is a shameful waste of money and time. If I can meet the meaningful use guidelines using a typewriter, then who cares if the typewriter is certified or not?

Moral of the Story (since this isn’t one of my clearest posts): This whole idea of modular certification is going to be messy.

One of my more interesting meetings at AAFP was with a company called SLI Global Solutions. The meeting was so interesting, because SLI Global Solutions plans to apply to become an ONC-ATCB organization very soon. This coming after the announcement of the first ONC-ATCB certified EHR from Drummond Group and CCHIT along with the announcement of InfoGard as an ONC-ATCB and Weno Healthcare’s plans to become an ONC-ATCB.

We obviously had a long conversation about the EHR certification, but suffice it to say that SLI Global Solutions is going full steam ahead to become an ONC-ATCB. It sounds like they’ve been doing a number of other certifications previously. They’ve even done some consulting work in healthcare.

When I asked SLI Global Solutions what they thought would help them to differentiate themselves from the other ONC-ATCB, one response was that they were really good at providing feedback and helping organizations through the certification process. I personally think that many EHR vendors and other healthcare organizations that need to certify for the EMR stimulus money are nervous about the unknown issues related to certification. If SLI Global Solutions can provide them a feedback loop then it could go a long way to relieving the nerves. This is the main suggestion Jim Tate makes in his post about selecting an ATCB.

I asked SLI Global Solutions how much they planned to charge for the EHR certification. Here was their response, “We have not finalized the pricing yet because we are contemplating ancillary services pre and post certification but we will likely be in the $20,000 USD ballpark.”

With SLI Global Solutions, that would make 5 ONC-ATCB and I’m guessing there are other companies like this that will become certifying bodies as well. I’m all about competition and so the more ONC-ATCB the merrier.

It does make me wonder how many ONC-ATCB the market can support. Not to mention, there’s the interesting question of whether they’re a bit late to the party. I guess time will tell.

Today, CCHIT announced their first ONC-ATCB certified EHR a day later than Drummond Group’s ONC-ATCB announcement. Although, CCHIT is announcing 33 EHR vendors (21 complete ONC-ATCB certified EHR and 12 module certified). No real surprises on this list. They were the previously CCHIT certified EHR companies. That gives us 36 total ONC-ATCB EHR right now (or 24 if we’re talking complete EHR certification).

Here’s the list of Complete ONC-ATCB certified EHR:
ABEL Medical Software Inc.
ABELMed EHR – EMR / PM

Allscripts
Allscripts Professional EHR

Aprima Medical Software, Inc
Aprima

athenahealth, Inc
athenaClinicals

CureMD Corporation
CureMD EHR

The DocPatientNetwork.com
Doctations

eClinicalWorks LLC
eClinicalWorks

Epic Systems Corporation
EpicCare Inpatient – Core EMR

Epic Systems Corporation
EpicCare Ambulatory – Core EMR

GE Healthcare
Centricity Advance

gloStream, Inc.
gloEMR

Intuitive Medical Software
UroChartEHR

MCS – Medical Communication Systems, Inc.
iPatientCare

Medical Informatics Engineering
WebChart EHR

Meditab Software, Inc.
IMS

NeoDeck Software
NeoMed EHR

NextGen Healthcare
NextGen Ambulatory EHR

Nortec Software Inc
Nortec EHR

Prognosis Health Information Systems
ChartAccess

Pulse Systems
2011 Pulse Complete EHR

SuccessEHS
SuccessEHS

Here’s the list of module ONC-ATCB EHR Certifications:
NOTE: CCHIT does make a comment that some of these may become complete EHR certifications later.
Allscripts
Allscripts ED

Allscripts
Allscripts PeakPractice

Health Care Systems, Inc.
HCS eMR

NexTech Systems Inc.
NexTech Practice 2011

nextEMR, LLC
nextEMR, LLC

PeriGen
PeriBirth

Sammy Systems
SammyEHR

T-System Technologies, Ltd.
T SystemEV

Universal EMR Solutions
Physician’s Solution

Vision Infonet Inc.,
MDCare EMR

WellCentive
WellCentive Registry

Wellsoft Corporation
Wellsoft EDIS

Drummond Group just posted the news of the first 3 EHR vendors which have been officially certified EHR for the ARRA EHR stimulus money. Looks like Drummond Group won the race to be the first to certify an EHR.

The interesting thing for me is the list of 3 EHR vendors that became the first certified EHR:
PARADIGM (QRS Inc.)
ifa EMR (ifa united i-tech Inc.)
ChartLogic EMR (ChartLogic, Inc.)

I consider myself pretty well informed about EMR vendors, but I only realy knew 1 of the 3 and I’d maybe heard of one other, but just by name. As all the ONC-ATCB certified vendors start completing their EHR certification, I think we’re going to learn about a WHOLE lot of EMR vendors that very few people knew about previously.

I also find it interesting that all 3 EHR vendors have already updated their website in some way to represent the new ONC-ATCB EHR certification.

Note: We need a new way to identify the certified EHR. ONC-ATCB just doesn’t have the right ring to it. I might work on this problem.

The good people over at >HITECH Answers must have more time on their hands than I do. They got on the CCHIT conference call where they talked about their newest ONC ATCB certified EHR program. Here’s a portion of the HITECH Answers summary which includes some CCHIT pricing details:

The ONC-ATCB Certified 2011/2012 Toolkit will help prepare health IT companies and EHR developers for testing. You can purchase the toolkit for $1000. Pricing will be in tier levels and range from $8K to $34,300K. They want to do the testing in a single day. There can be an accumulative approach where modules can be certified and added to the current certification without having to retest previously certified criteria.

It still feels wrong that they charge you $1000 for the toolkit you’ll need to use in order to pay them $34k more dollars to become certified. Uhh…yeah.

The fact that you can use a cumulative approach to certification is a difference between CCHIT and Drummond Group. Drummond Group has said that you would have to recertify everything if you wanted to do more modules.

HITECH Answers also mentioned that CCHIT has a program called EACH (EHR Alternative Certification for Hospitals) that will certify EHR technology in place for legacy and custom programs. They’d been calling this the EHR site certification before.

They also did a quick poll on the CCHIT call with the following results:
“Using the interactive polling option of the meeting, CCHIT asked attending vendors what their plans on certification were. In a quick response from about 250 vendors, 24% said they were intending to certify immediately, 45% said in the next few months, and 8% where not sure.”

Don’t ask me what the other 23% of responses were. However, these results do point to my belief that most EHR vendors will certify.

In my previous post about the EHR certification costs, a reader emailed me that I’d missed an important downstream cost. It’s not as much a cost for the EHR company as it is for the current user of an EHR system. It’s the cost for a current EHR user to upgrade their software to the latest and greatest version of the EHR software. You know, the one that is certified and allows you to show meaningful use of that EHR.

All EHR Will Need to Update
Lest you don’t think this is going to happen, I can pretty much guarantee that EVERY EHR company will need to upgrade their software to become a certified EHR and meet all the meaningful use requirements. The good thing is that most EHR users have a contract that provides them with all the upgrades free. Although, there might be some users that will incur a cost to upgrade.

Less Visible Update Costs
Beyond the potential cost to get the upgraded software, there’s also the cost to physically update your EHR software. There’s the very apparent cost of having to run a software install on all the computers in your clinic. This is pretty negligible for a small clinic with only a couple computers. However, in one clinic I supported we had 100+ computers and so the update process did take time.

However, more important than the actual software update is the process of preparing for the update. Certainly you could just update the software and go forward with it. Although, this is far from recommended and can be really problematic. I should cover this topic in a future blog post, but suffice it to say that the upgrade process goes much better when you 1. Look over the new features/changes to the EHR softare 2. Test the changes to see how they work 3. Train your staff on the new changes and how it will affect their workflow. These are all pretty academic steps, but they do take time.

SaaS EHR Vendors
Of course, the SaaS-hosted EHR vendors will all really enjoy this part of the process. They can easily update their EHR software to meet the guidelines with little interaction or work from the customer end. They still could cause the headache of an update to their EHR software affecting a clinic’s workflow. However, most SaaS EHR software companies are doing many regularly scheduled smaller updates as opposed to the large traditional client server EHR updates. These smaller changes generally cause fewer issues or at least spreads those issues out over time.

Even More Hidden Update Costs
I recently was aghast to learn of the EHR update requirements for a certain very popular EHR vendor. They’d told a clinic (or at least given them the impression) that in order to update their clinic to the latest EHR software that met the meaningful use and certified EHR guidelines (which is kind of silly since there still aren’t any officially recognized Certified EHR, but I digress) that the clinic would need to have computers that ran the Windows 7 Operating System. The sad news for this clinic was their current Windows XP machines weren’t powerful enough to run the Windows 7 operating system.

Let me translate what this means for the less tech savvy readership. The clinic would need to buy all new computers and the Windows 7 operating system (which should come on the new computers) in order to upgrade their EHR software to the latest meaningful use-certified EHR software. One could certainly argue that the clinic might need to upgrade these older computers anyway, but something doesn’t feel right about this being “forced” on a clinic. I personally still use Windows XP and don’t see much benefit to pay for a new computer with Windows 7. I will at some point, but there’s no compelling reason for me to move now. Why should clinics be forced into this expense by an EHR vendor?

Certainly Windows 7 and Windows XP are not ALL that different, but be sure that the change will cause some heartache in a clinic. Some mundane task that a user use to do easily in Windows XP will require a change to make it work in Windows 7. It’s easy to quantify the cost of new computers with Windows 7. It’s much harder to quantify the cost of this heartache.

Ongoing Update Costs
Many of these costs aren’t generally meaningful use specific. These costs or some variation are going to be part of the EMR update costs going forward. Unless your EMR vendor stops updating. Although, if your EMR vendor stops putting out updates, then you have a much different problem to deal with.

I’ve written previously about the cost of EHR certification with Drummond Group and CCHIT. However, this just addresses the hard cost of certification that’s paid to the certifying bodies. This cost doesn’t take into account a lot of other costs associated with becoming a certified EHR like the cost to develop and test the features that certification requires.

Keith Boone on his blog Healthcare Standards has done a great blog post that evaluates the other costs associated with certifying an EHR software beyond the fee you pay to the certifying body. If you’re an EMR vendor, this is an article that you definitely want to look at and consider. Plus, I’d love your feedback on things he missed or where he might have missed costs or estimated to high on costs.

Here’s Keith’s projections for EHR certification costs based on his estimates:
Average yearly developer salary: $80,000
Fully Burdened yearly cost: 200,000 – 240,000
Times the length of the project (~5.5 years)
Total certification labor cost: $1.1M – $1.32M

Of course, this number matches the estimates that came out with the HITECH act as well. ONC estimated between $500k-$1.5 million. So, this is pretty close.

I’ll leave the impact (good or bad) of this expense open for discussion. I think most people know where I stand on it.

I can’t remember when or where I saw it, but at some point I saw someone reference Jim Tate from EMR Advocate as the expert on EHR certification. I’d known Jim electronically for quite a while having followed his writings online and on Twitter. I even haphazardly bumped into Jim where we both looked at it each other and recognized our pictures from Twitter.

After Jim stopped by to comment on my previous EHR certification post, I emailed Jim to ask him if he wanted to do a guest blog post for EMR and HIPAA. He is busy with 3 stage 1 EHR certifications this week, but did send the following info which I found interesting and useful. I’m also looking forward to taking a look at his manual on meaningful use. I hear it’s highly targeted at doctors and clinical practices which fits in line with my style too.

The HHS/ONC Authorized Certification Program has really broken loose. We were in the eye of the storm, but the eye has passed and the windows are being blown out. Vendors are desperately trying to get a testing date in October and not Novemenber or later. The ability to get Stage 1 Certified and listed on the ONC website is now a giant business issue. A two month’s delay in being able to market and sell certified technology is a handicap. We will see the effect that decisions made over the past year by vendors will play out in the market. Those that applied for the CCHIT Preliminary IFR Stage 1 test are sitting pretty as their can choose test dates based on their application date. Those vendors that elected to wait may pay a price in delayed certifications. Of coursethere are presently 2 organizations authorized to test and certify and I expect maybe 2 more in coming weeks. That may help the crunch. The Drummond Group is charging $23,500 for all Stage 1 testing for EPs and has begun accepting applications for testing. Information about their program is available at: http://www.drummondgroup.com/pdfs/EHR_Testing_and_Certification_Guide_Rev_A.pdf (PDF). A number of my vendor clients have applied and have been given test dates in mid to late November. CCHIT will hold a Town Call next Monday at 1 PM ET: http://www.cchit.org/about/towncalls/CCHIT-Town-Call-Authorized-HHS-certification-program. The fees for their Stage 1 testing will be announced at that time and applications will begin to be accepted that date. Vendors who had already applied for CCHIT’s Preliminary Stage 1 Testing will begin testing against the CMS Final Rule next week. By the end of this month we will Certified Technology listed on the ONC website.

Due to the complexities of the CMS EHR Incentive Program for EPs I have written a manual, The Incentive Roadmap, to help guide medical practices through the process. It is being updated continually to reflect the changes in the incentive program. It is being sold at HITECHAnswers.

As I mentioned in my previous post about the race to be the first EHR certified (and the first ATCB to certify an EHR), there’s a lot more going on in the battle amongst the EHR certifying bodies.

The first interesting detail surrounds the previous CCHIT certified EHR vendors. This turns out to be a really great move by CCHIT. A quick look at CCHIT’s website has 49 EHR products (or modules of products) that have been certified for either the CCHIT 2011 certification or for the Preliminary ARRA certification. That’s 49 pieces of EMR software (a few less since some are different versions of the same product) have paid $22k+ in order to be certified by CCHIT.

I’ve talked to one of these EHR vendors and they said that CCHIT did a call with all current vendors and said that they will be honoring their previous commitment to provide the real ARRA certification at no additional cost to these providers. This turns out to be really smart if it means that many of the big EHR players like GE, Elipsys/Allscripts, NextGen, Epic, Athena, Pulse, Cerner, etc all decide to continue forward with CCHIT.

Many would ask why they would pay another $20k to someone like Drummond Group if they could get the EHR certification for free from CCHIT. Turns out their is a possibility if CCHIT isn’t able to deliver their certification in a timely manner and Drummond Group is able to do it much quicker.

Remember the list above are HUGE EHR vendors where $20k is basically a drop in the bucket. It’s kind of scary to consider that, but that’s the reality for most of the EHR vendors. Sure, it’s not what they’d like to spend if they don’t have to, but when did large corporations start worrying about wasteful spending? Ok, that might be a slight exaggeration, but you get the point.

The good thing for Drummond Group is that there are still 300+ EMR vendors that will need to be certified. In fact, many of the non CCHIT certified EHR companies are likely moving to Drummond Group for EHR certification since CCHIT is giving priority to their existing EHR vendors.

Yes, that’s right. Over the next month and half CCHIT will spend all its time doing a bunch of free EHR certifications while Drummond Group will be making just under $20k for each EHR certification that they do.

One final thought about the fun that is EHR certification. When I recently talked to an EHR vendor that is CCHIT certified and will likely be getting their now free EHR certification, I found it really interesting to learn who from their company was on the CCHIT call. In this case, the EHR vendor’s VP of Marketing was on the call with CCHIT.

Of course, this begs the question why the VP of Marketing would be on a call about EHR certification standards and compliance. Shouldn’t the clinical director be the one that wants to be on that call? I think it sends a compelling message that I’ve been preaching on EMR and HIPAA for a long time. EHR certification is not a benefit to the doctor. EHR certification is not a benefit to the patient. EHR certification is a means for EHR vendors to market their EHR software.

I have a lot more to say about EHR certification and the battle we’re about to see between Drummond Group and CCHIT for EMR vendors, but I’m about to leave for an interesting conference on meaningful use, EMR and HIE. Although, I did want to just start the conversation on becoming a certified EHR.

It seems like the battle is just beginning to try and secure EHR vendors under a certain certification. One of the competitive differences right now is about speed. Which EHR certification body will be the first to certify an EHR under the ARRA guidelines. It will be a big PR move for the first EHR vendor and should benefit Drummond Group or CCHIT to be first.

From the dates that I’ve heard, Drummond Group seems like they’ll be accepting applications for certification first (near the end of this month). CCHIT will be doing it at the beginning of October. It will be interesting to see how quickly Drummond Group will be able to turn around the EHR certification results.

Plus, one other wrinkle in this area is that CCHIT is giving priority to the EHR vendors that are already CCHIT Certified or Preliminary ARRA certified. This means the other 250+ EHR vendors are being treated as second class citizens. You can guess where that larger part of the EHR market is going for their certification: Drummond Group.