Alfred from Infomd.net recently made the following comment:
If the product you use is CCHIT certified, it is a pretty safe bet to say that they will be certified under the Meaningful Use rule. Meaningful Use is but a subset of what it takes to become CCHIT certified

Here’s my response to Alfred:
Alfred,
I don’t think that the new certified EHR is a subset of CCHIT. There are some similarities and concepts, but it’s not a subset.

However, I think you’re right that many CCHIT certified vendors will become ARRA certified. Mostly because the EHR vendor that has the CCHIT certification has chosen to make EHR certification a priority for their company. So, they’ll likely make the ARRA certification a priority as well.

It is worth asking if you want to be tied to an EHR company that focuses so much on certification. One could make the argument that an EHR vendor that focuses so much on EHR certification might not be focusing enough on the customer’s needs. These 2 focuses will obviously create very different EHR products.

See Also this post: EMR Stimulus Q&A: Do You Have to Use a CCHIT Certified EHR Vendor?

Today I came across some really crazy news that one of the senators that helped write the healthcare reform bill hadn’t ever even read the entire bill. Here’s a section of the article:

During the debate over what later became the health care bill that was recently signed into law by President Obama, a number of federal representatives and senators both admitted that they had not read it. Some, including Rep. John Conyers (D-Mich.) even boasted of this fact. House Speaker Nancy Pelosi (D-Calif.) famously stated that “we have to pass the bill so that you can find out what is in it.”

Presumably the actual people who wrote the bill might have at least some idea what was in it. Unfortunately that isn’t the case with Max Baucus (D-Mont.), lead sponsor of the Senate bill that became law. He admitted as much Monday during a constituents meeting in the small Montana town of Libby, as reported by the Flathead Beacon, a local newspaper.

According to Baucus, the idea of him reading a bill allocating nearly $1 trillion of federal funds is “a waste of time:”

There’s just something that feels really wrong about the idea that even the senator that helped write the bill hasn’t read it all. Although, it’s not really all that surprising.

I’ve thought that the same thing happened with the HITECH Act. No doubt it was thrown together by a few people and the majority of senators had no clue what it really included or meant.

Can’t you imagine it? They kind of throw together this EHR certification term tey’ve heard. Yeah, certification sounds good. Also, let’s make them accountable by making sure they’re using the EMR. Ok, the rest of the details are up to you.

I’m sure that no senators or even junior staff actually thought much about the impact of requiring a certified EHR and how they might measure a doctor’s use of an EHR.

Of course, why should they “waste their time” on a mere $20-30 billion. They can’t waste their time on a trillion dollar ill, so why would they waste it on a so much smaller amount?

I think I better just invite BobbyG to join me as a blogger since he’s often contributing essentially great blog posts in the comment. I just have to highlight them. So, here’s one comment that BobbyG offered that talks about the potential productivity loss that a clinic could see if they focus too much on meaningful use and not enough on the business case for implementing an EHR. I think we all know where I stand on this issue. If you don’t, then you should be reading EMR and HIPAA more often;-)

One of my concerns regarding a “stimulus focus” (i.e., an incentive money fixation) in lieu of a broader “business case focus” goes like this, if you will permit what may be a simplistic example:

ASSUME

[1] an average 2 minutes additional MU documentation burden per chart (that’s only 6 seconds on average to navigate to/”touch”/verify/enter each of the requisite 20 measures as needed for each patient during the attestation period);

[2] 100 patients seen per week, 50 weeks per year, or 5,000 charts touched annually;

[3] That’s 10,000 minutes, or ~167 hours;

[4] Multiply by a blended, fully G&A cost-multiplied FTE rate of $40/hour;

[5] 167 hrs/yr x $40/hr x five years = $33,400 MU labor,

exclusive of the FTE burden associated with the additional CQM reporting (“Clinical Quality Measures”). Now, recall that the max provider Medicare MU incentive reimbursement over the 5 years is $44,000 (and that money will be taxable income).

Worth it? Draw your own conclusions. Play with the input assumptions.

Now, obviously, the task (from my REC Adoption Support perspective) is to so effectively re-design workflow as to totally mitigate/eliminate any additional MU documentation burden while streamlining workflow ops more broadly, so that the MU incentive money is neither effectively erased nor appreciably diminished by all of this, and the provider is better off both financially and in terms of care quality and patient satisfaction.

We shall see, I guess.

While my illustrative scenario proffered above is rather simple and to a degree hypothetical, it is nonetheless based to a degree on my own playing around, stopwatch at the ready, in a “sandbox” e-MDs login provided us by the vendor, noting the navigation paths to the various MU “money field” target destinations.

A few seconds here or there, annualized, adds up quickly.

Long time readers will know that I’m not a fan of EMR certification. It seems quite pointless since it provides no assurance to the doctor of anything of value. EMR Certification doesn’t ensure a higher implementation success rate. EMR Certification doesn’t improve patient care. EMR Certification doesn’t improve doctor’s bottom line.

With that said, we’re still stuck with the term “certified EHR” in the HITECH Act EMR stimulus money legislation. So, EMR certification is going to be around for the foreseeable future.

CEO Mike from Medscribbler EMR posted an interesting look at the cost of CCHIT EMR Certification and the impact that it could have on EMR vendor selection and long term viability of EMR vendors. I’ve included his comments below:

Note: See my post about whether you have to use a CCHIT Certified EMR vendor before reading Mike’s comments.

Using the CMS’s own data and report a CCHIT EMR will spend between $125,000 to $350,000 in programming costs to be certified (add at least $20,000 for actual certification) An existing EMR not CCHIT certified they predict will spend $175,000 to $700,000 to meet the standards (plus the $20,000.)

Certification has to be done for each year, for three, so a 2011 certification does not guarantee MU certification for 2012.

Self certifying for Open Source are not exempt from requirements so it stands to reason they will have the same expense.

What does this mean:

1. Forget collecting MU with Open Source software.

2. If you are using no CCHIT software it is unlikely the software will be qualified by the vendor.

3. Even fewer EMR vendors will certify than those that did so for CCHIT.

4. Innovation is dead if MU certification becomes generally why an EMR is purchased as this will also set the preception of useability. Vendor design resourcess will go to MU not useability.

5. If MU EMRs fail to get widespread purchase, those EMRs who certify are dead (including some current larger market share ones, as they will undoubtably spend a ton on marketing to maintain their share.) The MU EMRs will also then presummably be left behind by the innovators for useability.

6. Certifying bodies, especially CCHIT may be in trouble because there will be fewer takers, or they will charge a lot more pushing EMR prices up.

7. Regardless everyone is going to pay a lot more for an EMR making the MU payment mote.

Medscribbler could be certified, we are still evaluating this, because there are a lot of CCHIT EMRs now dead in the water – certification is no guarantee of success – we believe useability is – and how do we balance useablity which will guarantee success with certification which may or may not?

Pauline Murphy asked the following EMR stimulus question:
If a chiropractor does not write perscriptions, does he still have the same e-prescribing requirements for “meaningful use”? How does that work, does anyone know?

Amanda Doss from Computer Link offered this answer:
No, the chiropractor would not have the same e-prescribing requirements for Meaningful Use. Page 61 of Meaningful Use discusses the “inapplicability” of measures to various provider types.

Basically, your chiropractor will have a denominator of “zero” for that measure. Also, on page 99 of Meaningful Use, you find (talking about e-prescribing) “this objective and associated measure do not apply to any Eligible Provider who writes fewer than one hundred prescriptions during the EHR reporting period.”

Good question and a great answer. I’m going to have to dive into page 61 some more and see how else it might apply.

Check out some of the previous EMR Stimulus Question and Answers.

After my last post, a meaningful use checklist, I couldn’t help but start thinking about how many people are going to soon be looking for a meaningful use checklist.

Certainly many practices are going to be interested in finding a meaningful use expert to help make sure that they get the EMR stimulus money. I’m guessing many EMR vendors are going to want to find a meaningful use expert that will help them navigate the hundreds of pages of regulations and wave of other meaningful use information which isn’t in the regulation cause let’s be honest. Despite a HUGE regulation, there are a still a ton of practical meaningful use details that you’re going to need to know to appropriately navigate the meaningful use world. The government doesn’t just hand out money (usually). You have to play the game.

The challenge is that who is a meaningful use expert. Just over a year ago, no one even used the term meaningful use. Over the past year we’ve learned a lot about meaningful use and each day we learn more, but it’s all one huge learning process for everyone.

Plus, it’s not like there’s some meaningful use expert certification. ONC and CMS have done some meaningful use conference calls and other training. I expect they’ll do more and more of these. Will those and other resources on the various HHS websites get us to the point that someone can say they’re a meaningful use expert? It seems like they’re going to have to do it, no?

Of course, we have the RECs also. No doubt, they should have the information you need to show meaningful use. Their meaningful use experts are free too. Not too bad. Are RECs getting extra meaningful use training that really will make them experts on meaningful use?

I’m interested to know how practices are planning to approach meaningful use. Will they be finding meaningful use consultants? Will they be using the RECs? Will they be navigating the meaningful use waters alone and build the expertise in house? Will they be relying on their EMR vendor to provide them the meaningful use expertise?

I guess it’s just hard for me to call anyone an “expert” on meaningful use. I think I’m pretty knowledgeable on meaningful use, but I’d definitely shy away from using that “E” word. Maybe other people see it differently than I do.

A recent comment from Jim Hook from The Fox Group had a nice checklist of items that doctors and practice managers could start doing to make sure that their EMR implementation is ready to meet the meaningful use standards. This isn’t an exhaustive list, but I thought was a good list for those providers wanting to being their preparation for showing meaningful use and obtaining the EMR stimulus money.

Everyone should keep in mind that there are no systems “Certified” at this point.

Here are some things to check as you get ready to claim your incentives for EHR Meaningful Use under the HITECH Act. This information is based on (EPs) qualifying for the Medicare incentives.

1) Start talking to your vendor about their plans to submit their EHR software for certification as “Certified EHR Technology”. The system does not have to be certified as of January 1, but it does need to be certified by the end of the 90-day period you are using to attest to your EHR Meaningful Use.

2) Keep in mind that if you are using a stand-alone EMR product with an existing legacy practice management (PM) system, the system needs to be Certified EHR Technology also. This is because some of the functions of a certified system, such as recording patient demographics electronically, are most likely functions of your PM system, not the EMR product. So talk to that vendor, too.

3) Verify that any eligible provider attesting to meeting EHR Meaningful Use objectives provides 10% or more of his/her Medicare services in an outpatient setting (not inpatient or in a hospital ED). CMS will look at the percent of services rendered in an outpatient setting for the fiscal year ending 09/30/2010 to determine the IP/OP percentages. Your EHR healthcare consultant must be qualified to do the analytical and reporting work in preparing the self-attestation report, based on the current fiscal year and the individual EHR Meaningful Use objectives in place, starting January 2011.

4) Make sure all eligible providers you are planning to certify for EHR Meaningful Use have an NPI number and are enrolled in PECOS.

5) For EPs in group practices, confirm the tax Id number – group or personal – of each provider for payment of the incentive amount. Payments can be made to either number.

6) CMS will be establishing an Internet-based enrollment process for EPs planning to apply for incentive payments. Keep checking this site for the Registration process, and enroll when it is available.

7) As soon as you start the clock on your 90-day period, make sure you are meeting all the EHR Meaningful Use objectives applicable to your practice, and, for objectives with numerical thresholds, that you are attaining the levels specified. If your EHR system is Certified EHR Technology, it should be capable of supporting all Stage 1 Meaningful Use objectives.

8) Monitor the CMS website on EHR Incentive Programs to determine the format of the attestation for 2011. And keep in mind that accuracy is paramount; attesting to EHR Meaningful Use is making a claim to a Federal program. And the penalties for false claims are significant!

Attestations can be completed as early as April, 2011, and CMS has stated payments will be made in May. For EPs seeking incentive payments under the Medicaid / Medical program, visit the CMS website for further information.

I’m always interested in the reactions of EMR vendors to various news. Granted, much of it is very predictable. They obviously want to sell more EMR software and so their reaction is usually a positive one when we’re talking about billions of dollars of stimulus money.

This is why I was so interested in hearing Evan Steele, CEO of SRSsoft’s response to the final meaningful use rule. Evan has been a strong proponent of maintaining the productivity of the practice and no doubt government regulations like meaningful use can stand in the way of that goal. The following is Evan’s response to the meaningful use final rule:

While the final rule on meaningful use contained some changes from the proposed rule, these modifications are only deferrals, not permanent changes. Everything that was taken out of the proposed rule will be added back in, according to Farzad Mostashari, and the flexibility granted for Stage 1 will be removed in Stage 2, just two short years away. The bottom line for physicians has not changed:

• Compliance with meaningful use will result in a significant decrease in productivity because the demands on physicians are still onerous and because it requires use of an EMR that is data-driven (traditional, point-and-click EMR) rather than workflow/productivity-driven (like the SRS hybrid EMR).
• The meaningful use measures are still not particularly relevant to specialists, as HIT Policy Committee member Gayle Harrell pointed out during the recent committee meeting.
• Participation in the government program is voluntary, as David Blumenthal made clear during the press conference announcing the release of the final rule. Physicians can choose to follow the compliance path or they can elect to pursue the productivity path.

SRS remains committed to physician and practice productivity and will continue to focus our development resources on our flagship product—the unique, productivity-enhancing hybrid EMR. Most high-performance specialists recognize that the cost of complying with meaningful use far outweighs any incentives that might possibly be earned or any penalties that might be imposed.

As you referenced in a recent post, SRS has entered into an alliance that will ensure that physicians have all the options they need. With SRS, they can reap the significant benefits of the productivity path, with the assurance that if at some point in the future they decide to pursue meaningful use, they will be able to do so as clients of SRS.

Looks like Evan is still preaching the EMR productivity message, but there’s a small sliver of hope for meaningful use with SRSsoft. I’m pretty sure every EMR salesperson is going to be so tired of hearing about meaningful use that Every EMR vendor will need a solid meaningful use strategy. Meaningful Use is here to stay. At least until the EMR stimulus money runs out.

Seems like we’re just about out of the daze that is the mammoth meaningful use final rule (yes, I know that other rules are even bigger, but it’s still mammoth). I thought it would be interesting to ask what’s the part of meaningful use that’s most concerning. Just so we’re not always pessimistic, I’ll follow up this post next week with one asking people to share the most exciting part of meaningful use. Both answers should be interesting.

While I don’t want to bias your comments, I will say that the thing that concerns me most about meaningful use is physicians going deep into debt for an EMR system they barely want in the hopes of EMR stimulus money and then end up with no stimulus money.

The first concern with this is those physicians that think they have to go into deep debt in order to fund an EMR. In most cases, this can generally be avoided. There may be some debt involved, but it should be pretty minimal and the return on the investment should be understood from the beginning and should not include the EMR stimulus. Unfortunately, I fear that many won’t heed this advice.

Add on the past experience with government handouts and I can see many appropriately disgruntled providers who get left holding the bag which includes no stimulus money.

Ok, your turn. What concerns you about meaningful use?

AK sent me the following EHR Certification question:

Is it necessary to get CCHIT certified vendor just because you want to qualify for incentives or regardless you MUST go for a certified solution?

Because I make the case that one should go with the one that provides the most amount of value.

You only need to use a certified EHR (doesn’t have to be CCHIT certified either, but HHS Certified) if you want to get the EMR stimulus money. The only caveat is that if you don’t show “meaningful use” of a “certified EHR,” then in a few years there are 1-5% Medicare penalties for not using one and showing meaningful use. However, many people strongly believe that those penalties will actually never be implemented. Of course, that part is just conjecture and may or may not happen.

So, there’s nothing forcing physicians to use a certified EMR solution. More and more people are doing as you describe, ” go with the one that provides the most amount of value.” They make the valid argument that if you get $44k in EMR stimulus money and lose $50k in productivity then you would have been better to go with an EMR that can’t get you stimulus money, but still maintains or even improves your productivity (among other EMR benefits).

At one of my EMR stimulus speaking engagements, a physician came up to me after the presentation and asked, “If I don’t accept Medicare or Medicaid, then do I care about meaningful use or certified EHR?” The easy answer was, nope. He can just decide on the right EMR without having to worry about government requirements.

Some have suggested that insurance companies might impose the certified EMR or meaningful use requirements, but I personally think that’s pretty unlikely.