Now that the HIT Policy committee has marginalized CCHIT EHR certification and proposed that HHS define the EHR certification criteria, it only seems reasonable to ask whether HHS will do a much better job than CCHIT did at defining “certified EHR.”

What has me a little concerned is the process the work they’ve done in creating the meaningful use guidelines. They are too complicated and I believe will leave us with a lot of unhappy doctors. It makes me wonder if the same will happen with defining the EHR certification criteria. A few things do give me hope.

First, the HIT policy committee’s suggestion is for the EHR certification to remain focused on just those things which are applicable to the EHR stimulus money. This should provide HHS with an advantage over CCHIT since it should mean a much more simplified list of EHR certification requirements.

Second, I’m a big fan of Marc Probst who was one of the chairs of the committees that put together the EHR certification recommendations for the HIT Policy Committee. I’m not sure how much involvement he’ll have going forward, but hopefully he’ll have a good part in it.

I guess at the end of the day, I don’t think that HHS could do any worse and probably will be quite a bit better. I’m sure there will be some issues with what they create. The question is just whether they’ll be minor annoyances which can be dealt with or whether they’ll be major issues which will cause doctors to not adopt an EHR even with the $44k hanging over their head.

I posted previously a short summary of the changes to meaningful use in the final meaningful use matrix presented at the HIT policy committee meeting. As I’ve thought about these changes this weekend, I couldn’t help but remember the major problem I (and many others) had with the original meaningful use criteria being too complex.

My argument then was that the 22 meaningful use criteria as a collective whole were too much for a doctor’s office to complete in the current time frame. Unfortunately, it seems that the HIT policy committee has chosen to only make slight simplifications of the meaningful use matrix for hospitals (For inpatient CPOE, only 10% of orders must be entered electronically) and has actually added to the EMR requirements for ambulatory clinics.

I do think they’ve made a wise choice on marginalizing CCHIT for the “certified EHR” requirement, but I wonder how many doctors are going to be able to meet this lengthy laundry list of EMR requirements to show meaningful use. You should have seen the faces on the doctors I presented to as I briefly listed the meaningful use requirements. Far too many deer in headlights and people shaking their heads.

Of course, the government has one thing on their side. Many won’t look into the details of what’s required to show meaningful use and will implement an EMR not having a full knowledge of what will be required of them to actually get the EHR stimulus payments. Maybe EHR adoption will increase thanks to the stimulus money and very little of the money will actually be spent.

I read that the HIT Policy Committee meeting that happened on July 16, 2009 was a “big one” according to Chilmark Research. He said that “the committee went from hearing revised recommendations for Meaningful Use, to recommendations from the HIE workgroup and lastly recommendations regarding certification processes for EHRs.”

I was unfortunately tied up doing a presentation on ARRA EHR Stimulus money and so I wasn’t able to follow the event live (or on one of my twitter accounts). I know that Chilmark is planning to do some posts and I’m looking forward to those.

I also found this short summary from John Halamka about the changes to meaningful use in the final definition:
1. For inpatient CPOE, only 10% of orders must be entered electronically
2. For problem lists, ICD9 or SNOMED must be used
3. Advanced directives must be recorded
4. Smoking status must be recorded
5. Quality measures must be reported to CMS
6. Clinicians and Hospitals must implement at least one clinical decision rule relevant to a high clinical priority
7. Administrative transactions, including eligibility and claims, must be completed electronically

I think it was wise for them to split it out into an “eligible provider” and a “hospital” set of requirements since the needs are different, but at first glance it seems a bit like ambulatory clinics are getting a bit of a shaft in this regard. I’ll reserve final judgement until I have more time to really review the changes.

I do think this change as described by John Halamka is a good one: “The Meaningful Use Workgroup recommended use of an ‘adoption year’ timeframe (i.e., ’2011 measures’ applies to first adoption year even if HIT adopted in 2013; ’2013 measures’ applies to 3rd adoption year.”

This powerpoint about EHR certification was also presented at this meeting. There’s a lot of information in that powerpoint, but it looks like they’re proposing that CCHIT be relegated to a certifying body, but not be involved in defining the certification criteria. HHS will be defining the EHR certification criteria. I’m sure I’ll be writing much more about the content in this presentation. Lots to still digest.

I also found two draft transcripts from the meeting.

If anyone else knows of some other summaries from this meeting please let me know in the comments and I’ll add them here. Or feel free to make your own summary in the comments. I’m always interested to hear what people thought was important from meetings like this.

I’d been meaning to post this when the meaningful use document came out, but didn’t get around to it until now. ONC has asked for public comment on the preliminary definition of “meaningful use” as presented by the HIT policy Committee (see the Meaningful Use Matrix). Submissions are due by 5 pm est June 26, 2009, and should be no more than 2,000 words in length (per the HHS HIT website).

I encourage everyone involved in Helathcare IT to submit their thoughts on meaningful use. I’m a big believer in leveraging the knowledge of crowds to make something better. I believe that if you amass enough smart people on something, you usually get a pretty good result. Assuming that they listen.

I’d also certainly welcome people to post their submissions in the comment of this post if it’s something you don’t mind making public. I think it could be really valuable to have all the various submissions aggregated in one spot for everyone to review and consider.

Here’s the other details for meaningful use comment submission from the HHS website for those interested in submitting (nice that they have an electronic option):
Electronic responses to the draft description of Meaningful Use are preferred and should be addressed to:
MeaningfulUse@hhs.gov
With the subject line “Meaningful Use”

Written comments may also be submitted to:
Office of the National Coordinator for Health Information Technology
200 Independence Ave, SW
Suite 729D
Washington, DC 20201
Attention: HIT Policy Committee Meaningful Use Comments

As I first looked over the meaningful use matrix (PDF) that was created by the HIT policy committee I thought that the requirements listed were reasonable and doable. Then, I realized that I was only looking at the first page of a seven page document.

For now, I’ve focused on looking at the 2011 objectives. I wanted to really focus on it since that’s the bar with the most stringent timeline for those wanting to get the EHR stimulus money from ARRA.

I’ll talk in more detail about the various items in a future post. However, as I look through the list of objectives to show meaningful use for 2011, I don’t think any of them sound unreasonable. On their own, each objective listed seems to be something that is completely doable. I might question why some are on the list, but I don’t see any of them individually as too much to accomplish in that time frame.

The problem is that the 22 meaningful use 2011 objectives as a collective whole would be daunting for any practice. I previously wrote about the challenge hospitals face implementing an EHR quickly, but I think this list of objectives would be hard for a practice of any size. I guess some of the reporting could be centralized for a hospital system and save them some time. For a small office, they’d have to do all the reporting themselves and that could be time consuming. No wonder David Blumenthal, ONC head, sent the meaningful use matrix back to the HIT Policy Committee.

I see two other major problems I see with the meaningful use matrix. First, some of the requirements don’t even have established standards yet. Sure, it’s a nice concept to say that doctors should have to “exchange key clinical information.” That’s kind of one of the points of the legislation. Unfortunately, we don’t have any real established standard for sharing key clinical information between providers. CCR seems to have some merit, but is far from becoming THE standard for sharing clinical information. Seems like we’re getting cart before the horse when we ask people to do something for which there is no established and recognized standard.

Second, how is HHS/ONC going to measure accomplishment of these objectives? There not going to go around to each clinic to verify that they actually have an “active medication list” or that they “incorporate lab results in the EHR.” Maybe it’s just the practical side of me. It’s nice to have these objectives, but if we don’t have a way to meaningfully measure that the objectives are being accomplished then it will be abused. I think ONC and HHS might be responsible for deciding how to do this, but I think it would be naive of the HIT policy committee to make these recommendations without good ways to measure them.

I participated in both of the CCHIT “town calls” that happened this morning and yesterday. I did miss the beginning of today’s call, but looking through the slides it looks like the presentation was more or less the same for both town calls. You can see the slides from both CCHIT presentations here. Between this and the HIT Policy Committee meeting yesterday there’s almost too much to digest. So, in my regular fashion I’m going to break down my analysis into lots of bite sized chunks.

The biggest change that was proposed/announced during the CCHIT meeting was three EHR certification pathways:
EHR-C: Certified EHR Comprehensive
EHR-M: Certified EHR Module
EHR-S: Certified EHR Site

Basically, the EHR-C is the same certification that CCHIT has been doing since the beginning. Certainly the requirements for the EHR-C certification could be changed, added to, modified in order to meet the ARRA requirements, but for all intents and purposes this is what CCHIT has been doing for years.

The EHR-M certification is where CCHIT will certify certain modules from a software vendor. If my understanding is correct, CCHIT plans to take the various criteria that comes out of ONC and HHS and then use those criteria to decide which modules will be certified. An EHR vendor, or even other HIT product vendors, could choose to just get e-Prescribing EHR-M certified. I guess the thought here is that a hospital system, for example, could use one software vendor for e-Prescribing, another for EHR, and another for HIE and as long as they are all EHR-M certified, then the hospital could qualify for ARRA incentives.

The EHR-S certification is essentially where CCHIT will certify a site (better defined as an organization) to show that they meet the various ARRA requirements. It was made abundantly clear that the EHR-S certification only certifies that the site meets the ARRA requirements and not necessarily that the software that site is using meets the requirements. I’m sure this will be a topic worth discussing. Basically, the EHR-S certification tries to certify that a site is using an EHR to the ARRA requirements.

How’s that for a summary of the new EHR certification pathways? Did I misunderstand anything or leave anything out? Let me know in the comments and I’ll update anything that’s not clear.

Now, look forward to more commentary on the benefits and challenges of these paths, the timeline that CCHIT has proposed, CCHIT EHR ratings, CCHIT Certification codes, and of course plenty more discussion on the latest meaningful use draft document. I’ll try to space out the posts as much as possible so as not to overwhelm you.

The healthcare IT airwaves are abuzz with the date of June 16th.  That’s the date that they say we should get more indications on how the government is going to define the all important term “meaningful use.”  Here’s a short quote from John Halamka about the meaningful use dates:

On June 16th, the Quality workgroup will receive meaningful use guidance from the HIT Policy Committee. We’ll work hard over the following week and will present our strawman standards, implementation guidance, and certification criteria at the June 23rd public meeting of the HIT Standards Workgroup. We’ll continue to refine the matrix in July and complete our work in August.

John Halamka also described the format for the HIT Standards Committee’s meaningful use document:

On the call we discussed that the HIT Policy Committee will review a draft of meaningful use criteria at its June 16th meeting. Once this draft is delivered to the HIT Standards Committee, its workgroups can review the standards and certification criteria which map to meaningful use. Imagine a 4 column table

Column 1 – An aspect of meaningful use i.e. e-Prescribing

Column 2 – The standards and implementation guidance needed for meaningful use i.e. NCPDP Script 10.5 and RxNorm as implemented in the HITSP Capability document “Issue Ambulatory and Long-term Prescriptions”

Column 3 – The certification criteria i.e. Conformance testing using the CCHIT Laika tool for appropriate implementation of NCPDP Script 10.5

Column 4 – The meaningful use measure i.e. what percentage of prescriptions in a practice were e-prescribed?

The above examples are illustrative only – they are not work products of any committee.

Certainly we’re going to get some more information and fodder for discussion about the term “meaningful use” and it’s implications for EHR stimulus money. I’d just caution people from looking too deep into the document we receive on June 16th. As is said above, there’s still a few more committees that need to meet to refine this document.

I do encourage people to provide feedback and commentary on the June 16th document. I’ll be looking around to find the best avenues for people to communicate any comments on the document. If you know of any avenues to share your feelings on “meaningful use” please let everyone know in the comments.

As I’ve been writing and reading about ARRA and the HITECH Act, I’ve had a few moments to consider the impact that things like the HIT Policy Committee will have on the future of EMR adoption in the US. Between that committee, ONCHIT and HHS the decisions they make will have far reaching impact on EHR adoption. I’ll leave the question of whether they’ll have a good or bad impact to another post.

Instead, I couldn’t help but wonder what impact bloggers and various EMR related websites and forums can have on EMR adoption. More specifically, I’ve been asking myself what kind of impact does this blog have on overall EMR adoption including both selection and implementation. Maybe I should be asking myself the question of how much impact could EMR bloggers have on influencing the HIT policy committee, ONCHIT and HHS, but I think that’s basically falling on deaf ears.

Instead, I think that bloggers like myself can have a real lasting impact on specific readers lives. Hopefully those who visit my blog get a better understanding of why they should implement an EMR. I hope they find some guidance on how to select an EMR and avoid various EMR sales miscommunication. At a minimum, I think the people who have bought the high volume scanners I suggested will be really glad they found this blog. I’m not sure why else people visit this blog.

Maybe this is all a little too personal, but I’d love to hear people’s thoughts on the impacts blogs and other EMR related resources have on EMR adoption. I’d like to think that blog like mine can have a good impact on the EMR world and aren’t just a nice place for those in the industry to sit around the virtual water cooler.

Either way, as I write future posts, I’ll be taking some of this into consideration. I think this will also give me a little bit of added motivation to complete a series of e-Books on EMR selection and EMR implementation. Hopefully those can provide some real targeted and valuable information to improve those two vital areas of EHR adoption.

Marc Probst, CIO at Intermountain Healthcare and member of the new Health Information Technology Policy Committee, gave a really interesting interview to Healthcare Informatics. I really don’t know Marc Probst other than what I read in this interview, but I do know something about Intermountain Healthcare (or IHC as it’s known in Utah). When I was in high school I actually worked for IHC spending one hour a day cleaning a local doctors office. I’m glad those days are over and I don’t think I did a very good job at it either.

However, from that experience and also my high school friend’s dad being the CEO of IHC I got to know the company pretty well. I was really impressed with how the company was run. From the above interview I think that Marc Probst probably has quite a bit to do with that. Let me give a few examples of things he said that I liked:

AG: I completely agree about John (Glaser’s positive influence on defining “meaningful use”) and I’ve written as much. You may not know the answer to this, but there is also a Standards Committee that has yet to be formed. And there have been a lot of questions about what the differentiation might be between the Standards Committee and HITSP, John Halamka’s group. Do you have any information about the Standards Committee makeup, how it’s going to interact with the Policy Committee and the relationship of the Standards Committee to HITSP?

MP: I don’t know any of that, no.

AG: But they’re good questions.

MP: They are really good questions. Blumenthal has just gotten in and HHS still needs to finish their appointments, I think it’s just all very preliminary. Congress basically set down the dates for GAO to have to have the first 13 in place. But I don’t know if there are those same triggers out there for the other committee or the other seven on the Policy Committee. I think GAO has just met the timeline that they had to meet.

AG: We’re all just working our way through this, right?

MP: The best thing about standards is that there are so many of them, right? I hope the Standards Committee can become a brokering point to say, ‘Whether or not they’re the perfect standards, these are what we’re going to follow.’ Where does HITSP fit in this? Where does HL7 fit in this? I don’t know. We may only be 85 percent right in terms of agreement, but boy, it would be nice to have a target to go after.

Call me crazy, but I like I guy that’s not afraid to say that he doesn’t know. Makes me trust someone a lot more when they don’t try to fake something.

AG: Let’s not forget CCHIT.

MP: Do we have to talk about CCHIT?

AG: We can never leave any acronyms out as far as I’m concerned.

MP: CCHIT in my book is really good; I’m just concerned about a blanket rule that every system has to be CCHIT-certified, boy, that’s got a lot of challenges in that statement, and I’d be careful.

My understanding is that IHC built most of their EHR systems in house. This may be why Probst is not so happy with the blanket statement of CCHIT, but he realizes he has to be politically correct enough to not bash it (something I haven’t learned).

Let’s just say that I’m quite happy to see Marc Probst on the Health Information Technology Policy Committee. I’m adding him to my list of really smart and thoughtful people in healthcare.

One of my loyal readers and colleagues in the EHR field recently sent me a link (pdf) to the list of members that were announced on the Health Information Technology (HIT) Committee. Take a look at the list of members on the HIT Policy Committee:

• Christine Bechtel, vice president, National Partnership for Woman and Families
• Arthur Davidson, director, Public Health Informatics, Denver Public Health Department; director, Denver Center for Public Health Preparedness; medical epidemiologist; director, HIV/AIDS Surveillance, City and County of Denver
• Adam Clark, research and policy director, Lance Armstrong Foundation
• Marc Probst, chief information officer, Intermountain Healthcare
• Paul Tang, vice president and chief medical information officer, Palo Alto Medical Foundation
• Scott White, assistant director, technology project director, 1199 SEIU Training and Employment Fund
• LaTanya Sweeney, director, Data Privacy Lab, Carnegie Mellon University
• Neil Calman, president and chief executive officer, Institute for Family Health
• Connie Delaney, dean, University of Minnesota School of Nursing
• Charles Kennedy, vice president, Health Information Technology, Wellpoint
• Judith Faulkner, founder, CEO, president and chairman of board, Epic Systems
• David Lansky, president and CEO, Pacific Business Group on Health
• David Bates, medical director for clinical and quality analysis, Partners HealthCare/Brigham and Women’s Hospital

I think the person that sent it to me was surprised that someone from Epic, a private vendor, was on the committee. What was more interesting to me was that there wasn’t one representative on the HIT policy committee from a small doctor’s office. There was plenty of hospital representation and public health but no one to speak for the small doctors offices. Sad part is that small doctors offices make up the major part of the US healthcare system and should be the ones who really need to access the HITECH Act EHR stimulus money.

Looks like my list of HITECH Act EHR stimulus winners is becoming more true every day. My list didn’t include small doctors’ offices and neither did their committee.