An EMR and HIPAA reader, recently pointed me to a post on a Google Group called “Response to HIMSS ‘Call to Action’: Interoperability First.” The response starts with a short discussion of the need for government to promote and support some sort of interoperability standards. I’ve said a number of times before that interoperability should be a focus of government, because interoperability is more of a public health benefit than it is a benefit to doctors.
After discussing interoperability, the response discusses reasons why CCHIT certification is an inappropriate standard for the HITECH act to use to determine “certified EHR.” Take a look at the reasoning:
As it currently exists, CCHIT certification is an inappropriate standard for federal funding, authorization or endorsement of HIT systems:
*CCHIT 2009 certification has over 450 separate requirements, the collective effect of which tremendously increases the cost and complexity of IT solutions. Many of these requirements are “functional specifications” that should be determined by customer needs and priorities, rather than by committee. These requirements foster (if not mandate) the development of rigid, monolithic systems.*The monolithic approach to certification taken by CCHIT does not reflect the current advances in information technology being leveraged by other industries where integrated solutions are used to support the complete “end-to-end” business process. Integration and interoperability are essential to leverage the potential of “cloud computing” and other service orientated delivery mechanisms.
*CCHIT works to the benefit of a small number of large EMR vendors that can command a high price from the relatively small segment of the market able to currently afford their products. It is essentially anti-competitive, and establishes a major barrier to entry by new vendors and open source projects (where the majority of innovation will take place).
*A quick count from the CCHIT website gives the following results for the number of systems certified for ambulatory EMR (including conditional certifications and multiple certified products from a single vendor):
i) 2006 = 93
ii) 2007 = 55
iii) 2008 = 14*At this rate of attrition, the number of certified products will dwindle to the single digits.
*The shrinking number of vendors that are capable of meeting CCHIT certification exposes a fundamental flaw in its current organizational structure – CCHIT is funded by the very vendors it certifies. In order for it to maintain revenue, it needs to provide a reason for vendors to continue to either:
i) re-certify on a regular basis
ii) apply for new certifications*The problem with this model is that, in order to justify ongoing re-certification, CCHIT must continue to add new certification requirements year-to-year. The driver for more requirements is not necessarily the needs of customers or the best interest of the healthcare system, but the need to have new requirements against which to certify vendors. This is illustrated by the fact that CCHIT has recently reduced the length of the certification from three to two years, and is adding numerous supplemental certifications in areas like child health, cardiovascular, etc. There is no end to the number of requirements to which this could lead, but there is no evidence it will serve anyone well in the long run, other than the few large vendors with the resources to keep up with this process, and CCHIT itself.
*Although in theory vendors can apply jointly for CCHIT certification, in practice the monolithic certification process will limit the ability for vendors to provide component solutions from which customers can choose to create best-of-breed, low cost solutions that best fit their needs. For instance, in the ambulatory arena, this might typically be a combination of Practice Management, EMR and e-Prescribing solutions.
*Certification of Practice Management systems in other markets (e.g., UK) has arguably reduced innovation and investment, increased the total cost of ownership and consolidated the market to such a point that there is limited choice and the barrier to entry for new entrants into the marketplace is unaffordable.
I think this is just the start of what could be said, but it raises some really important points about certification.
You lost me at, “…the need for government to promote and support some sort of interoperability standards…”
The fact that “government” is used in the same sentence with “interoperability” is quite amusing. Any time the government gets involved with anything you can count on anti-interoperability.
While the attrition rate is high; you also must consider the fact that CCHIT Certification is good for 3 years; that may explain the large amount of people who signed up in 2006 and have not had to re-new certification yet.
Actually I just read that the new 2008 certification is only good for 2 years. Niceee CCHIT, milk some more money out of these guys….
Sam,
I still think that government could fund some of the promising standards out there in order to improve inter-operability. There’s no financial motives for doctors to do it, are there? I’m not referring to government’s direct involvement, but promotion and funding of interoperability standards.
It’s true that it’s good for 3 years, but if the certification itself provided value for the EHR vendors, then you’d think that they’d do it each year (like some have done). Instead, I believe that most vendors do it for the marketing advantage and nothing more. There’s no arguing that there’s a marketing advantage related to CCHIT certification.
The question for doctors is will it matter if someone is 2006 certified or 2010 certified. I’m not sure most practices will know the difference between the 2.
I agree the change from 3 to 2 years is CCHIT milking more money out of EHR vendors which gets passed on to doctors that purchase the EHR. Nice way to increase revenue on CCHIT’s part.
Believe it or not, there are very small vendors of EMR and PMS products for whom the CCHIT certification fees are prohibitive. We sell to behavioral health providers, solo practitioners, small groups, and small community agencies. They need very inexpensive products because their incomes cannot support even moderately costly ones. These providers don’t have the administrative staff to help them apply for funding. We expect massive retirements of our customers before 2012, or we expect that they will opt out of the traditional healthcare system and serve only private pay patients. They will likely be priced right out of their profession. What the effect will be on our company remains to be seen.
Kathy,
Not only do I believe you, I think that there are a lot of EMR companies that are in your same situation. I also think there are a lot of doctors and practices that are evaluating exactly what you describe. It will have a major impact on health care as we know it.
Thanks for your comments. They are dead on from what I can tell.
We develop an orthopedic specific EMR system and the best thing about the system is that it is not CCHIT certified. Our doctors love the system becuase it’s easy to use. There is no way an orthopedic surgeon can see 50-80 patient’s a day and use a CCHIT type of system. The ones that do usually hire a scribe to enter all the data, and I’ve heard stories after stories of other practices that purchased a CCHIT system and never implemented yet. I guess it goes back to the fundamental principal of CCHIT not paying close attention to each specialty. They even publicly announce that they do not certify workflow so they could really care less if physicians see less patients and generate less revenue.
Regarding the frequency of certification, active software developers produce product “upgrades”. on average every two years. I have noticed that for many vendors, the software version that was most recently certified is not the most current version. Is there a guarantee, other than full re-certification, that a product whose ancestor was certified three years ago would itself pass the testing today? I don’t see it.
Whether CCHIT is the most appropriate body for issuing certification or not, it is currently the only one doing it, and it does provide some assurances of product quality to potential purchasers and to the users of the information the systems produce.
Eric,
I can’t argue that CCHIT provides some assurance to doctors. They’ve done a masterful job marketing this. My problem though is that it’s providing an assurance that it really can’t make. I have yet to see a study that shows that CCHIT certification improves EHR implementation success rates or that CCHIT certified EHR are more interoperable or that CCHIT certified EHR are more usable by doctors or that users of CCHIT certified EHR are happier than non CCHIT certified EHR. However, this is the impression that CCHIT and the EHR vendors who are certified are giving to doctors.
I fully believe that the final goal is to have single digit CCHIT certified products that physicians will have to use to get reimbursed. Why do you think the CEO of a major EMR company out of Chicago got on the first plane to Washington as soon as Obama was elected to assist in “crafting” the legislation in the first place? It’s all about the money. And what about the physicians that purchase a certified product today that can’t make the certification process tomorrow? Does he keep making the investment in new systems? The whole certification process is completely absurd!
kcogs,
Looks like we’re going to get along really well. I’ll hope you’ll continue to contribute to this site in the comments. The more people sharing information the better.
If you think CCHIT certification is a problem for EHR’s, check out what they are doing to HIE’s. It is now cost prohibitivefor us to be part of the eHealth Exchange because CCHIT testing and certification is now required for participation. We were running in production with cms with a CONNECT Gateway and had to drop out when the fee’s came in after being announced by the operator, Healtheway, http://www.healthewayinc.org .
Lou,
Thanks for the note. I’ll put it on my list to look into. Sounds like they’re up to their old habits.