Small EHR Vendor and Specialty EHR Vendor Rant

The following was a comment made on my previous post about Meaningful Use attestation issues by Jon (man there are a lot of John/Jon’s in Health IT). As always, I do my best to bring out interesting topics for all to read. In this rant, Jon makes some interesting comments about the challenge of specialty EHR software to meet the MU measures. Something I’ve mentioned before, but Jon adds some more insight.

*start rant*

It is even worse for some small EHR vendors that have existed for over 20 years – like the one I work for. The government has no idea how ugly and not applicable many key elements of meaningful use (defined as the government chooses) are for non-primary care, highly specialized providers.

Here’s a conundrum that frames EHR certification and meaningful use in a way I rarely see it discussed (and would love for someone to explore more *hint hint*) – take a small, but established vendor of EHR software which is not yet certified.

This vendor provides software to a niche industry of highly specialized providers, who do not derive any real or identifiable value from meaningful use as it is defined (to keep things generic I will omit the specific part of the industry).

To get software 100% EHR certified you must fulfill all of the requirements, even if, as a vendor, your customers will not make use of, or benefit from, most of the functionality. Please take as an assumption (for this discussion) that only 30-40% of the EHR certification requirements are of value to the customer.

Since the customer will not make use of the functionality, they don’t want really want to pay for a 100% EHR certified product. But they sure would like the incentive money (or in the case of Medicare providers, will get penalized if they didn’t do meaningful use).

As a small vendor, your big competitors are all EHR certified (and some are even free), but even if it didn’t make sense for the customer – because the other (typically larger) vendor can afford to implement it, even if it is sloppy. Customers see a well-known product name from a large company is EHR certified – so EHR certification gives those who complete it an edge – even if it makes zero financial or functional sense.

I hate being a pessimist, as surely some good has come from meaningful use. However, as we are seeing by these posts, what value does EHR certification and meaningful use TRULY bring to the provider, other than the requisite piece of paper to get incentive money? We need to see many, many more successes, and in my specific case, we need to make sense of how to make something which is not useful… useful somehow.

Sure, the answer to this might be that in the long run, vendors with better or more applicable products will always win out, but we know that this isn’t always true based on long-term software contracts or lack of desire to switch vendors. Or the answer might be that highly specialized providers only account for 20% or less, and 80% of the provider population is primary care or similar handle meaningful use just fine. Or maybe that I’m just crying in my beer!

Nevertheless, we have this catch-22.. or an enigma wrapped in a mystery shrouded in a riddle.

*end rant* Comments? Thoughts?

One other note from John Lynn, I’m sure many large EHR vendors will probably say that if small EHR vendors can’t meet the MU requirements, then they don’t deserve to be an EHR software. Those that say this, are really missing the point. It’s not that they couldn’t meet the MU requirements, it’s a question of should they meet them in MU’s current state.

About the author

John Lynn

John Lynn

John Lynn is the Founder of, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference,, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • Yo Jon:

    I work for a small, primary-care focused vendor and I couldn’t agree with you more EXCEPT that the issue crosses into primary care.

    ~50% of pediatricians don’t qualify for ARRA $$ and the entire set of MU measurements were written with adults in mind.

    For example, in the original draft of the requirements, physicians were required to ask every patient about their smoking statuses. Yes, they were supposed to ask a newborn about the last time he smoked.

    The AAP pushed heavily and the rule was amended to start asking at age 13 – whew. However, the required answers for that data element don’t line up with answers pediatricians often get (“I tried a cigarette last month, hated it.”) Calls to NHIS confirm, “Oh, that standard was created for adults.”

    I could go on at length, but I’m sure this bores most people.

    From an behind-the-curtain perspective, we’ve created a term for what Jon describes: “ARRA debt.” That is, we had to develop a long list of semi-useful tools in order to pass ARRA certification that we now have to go back and “fix” in order to make useful. Using the smoking example above, we have to go back and give the clients the option to use the “ARRA” version of the tool or an updated on that reflects their actual flow and clinical needs. There are some ARRA “features” that our clients will never, ever see.

    So, our little niche company spent ~8 months cramming in all kinds of features with limited appeal rather than focusing on things our clients demand specifically. Why? Because “Are you certified?” is the FIRST thing every practice and REC consultant asks. As though that certification also covers the quality of your support and training, the likelihood of your company flipping to a conglomerate, or even the usability of your system.

    Once we got certified, we thought we’d be able to spend all our time working on the “fun” things that would make our clients happy, but now we have ~6 months of “ARRA debt” to work on instead.

    The Law of Unintended Consequences, I guess.

  • Don’t know if I would consider it a “rant” and more of a right on comment, John or Jon. Its no secret that the Certification Criteria are slanted to the advantage of big vendors in an attempt to weed the field of over 600 companies. They as much have said that through their comments about “prediction of the future” of EHR software. The drive for data to ration health care dollars trumps any nitch vendor usability advantages in their mind. CMS and ONC could care less if the specialist suffers a horrable experience daily trying to use clunky software that doesn’t fit their workflow as a result of the small vendor not being able to comply with criteria that is rediculous and irrelevant to their specialty served. They have a directive to get the data accumulated, start denial of payment based on data driven “performance” measures, and supposedly save US healthcare from bankrupcy. In the process, crushing many a small vendor with a superior product through irrelevant certification. There…counter rant.

  • A few things here…and believe me…I’m not defending the government:

    1) Any time (almost) the G creates rules/certifications, it will be a mess.

    2) When you to get paid by the G, you have to play by G’s rules…no matter how stupid/arcane/insane/ridiculous/etc they are. Those insurance companies run you through the gamut, also.

    3) I deal with many physicians who get “wrapped around the axle” about “stupid stuff” they need to track. Sorry, that is the game we’re playing…BUT…if you setup your workflows properly it really isn’t that big a deal. The same goes for CQMs.

    4) Maybe it is from my time in the military, but rather than look at the requirements and belly ache, Docs need to look at the requirements and say, “how do I make this as easy as possible”. That’s what I do for them at least.

    5) The EHR vendor world has changed drastically in in the last 5-ish years. I surely wouldn’t want to be in it, but again, this stuff isn’t rocket surgery…and one of your BIGGEST SELLING POINTS as a small EHR vendor should be:
    “Look the grand daddy of EHRs, Centricity, can’t get MU right, what makes us different is we care about our docs and we’ll fight to the end to make sure you get every reimbursement you have coming to you.”

  • Law of unintendend consequences – says it all. As a vendor who works with ONC, and having gotten to know them better, they do have the greater good in mind; and some of these hurdles are un-intended and un-foreseen. The Phase II of the meaningful use requirements are in pilot and this is a good time for the EHR vendors to work with ONC and point out the flaws which ONC will graciously accept and review. It has been interesting working with ONC and understanding their thought process goes a long way in positioning and requesting exemptions. Key here is for the EHR vendors to spend the time and effort and work with ONC helping to meet their objectives.
    On another note, while reducing the expenses is the goal, its more about the reduction of wastefull expenses which is being targeted to get the healthcare costs under control.

  • Chip,
    I think the concept of “ARRA debt” is an interesting one and a good way to describe much of it.

    They called it a rant so I followed their lead. If it was a rant with no foundation, I wouldn’t have likely republished it, so I’m glad you agree with their assessment.

    The odd thing is that they’re supposedly driving to get at the data, but they don’t even know what to do with the data.

    Anyone that went into this not realizing that the government requires something when they give out money missed the boat. That’s always been clear and not just in healthcare.

    I’d love to hear what you think the best ways that an EHR vendor can get involved with ONC are. Which outlets have given you the most success?

  • John, ONC maintains an extensive directory and blog of what they do at WIKI and any company interested can join. In order to realize value, the companies interested should be able to dedicate one or two senior resources towards this; there are many pilots that go on related to MU Phase II; the EMR companies can participate in the Pilots, provide their inputs and the ONC group is more than willing to listen. Actually, this is a great group of people to work with and they take the input and integrate that within the initiatives framework. We do not participate in all the Pilots – we are participating in two of them currently.
    I believe its better to participate and shape the outcome as opposed to sitting on the sidelines and later on finding fault in such initiatives…………..

  • Wanted to thank all for the comments on this post. It’s reassuring to know we’re not alone in the struggle. In the end, MU is a lot of work and energy that will be spent… and perhaps could have been avoided with the same end result achieved… but it is what it is. You either survive it, ignore it, or do it really well.

    Regarding working with ONC, that’s a nice suggestion, and I have attended (virtually) the IT Policy committee meetings and others. I didn’t find the folks there super willing to adopt things to the segment of the industry I am in, although they were aware of and at least willing to listen to some of the challenges it faces (although wishes don’t do dishes).

    For that matter, it is difficult to stand up in a public forum like that and ask the questions like, “why do I have to do X requirement” when “X requirement” doesn’t really apply to my industry? Answer.. “because everybody has to do it” – that’s the bar and you either meet it or you don’t.

    Honestly, the bigger problem is the time it takes to work with these external work groups/agencies – time that as a small company, I really have to invent out of thin air.

    Before MU, we were already automated, innovating, and actively addressing our customer’s needs. MU changed the customer’s “needs” by adding needs external to them to their list. Their existing needs? Well those get bumped down a few notches. Again, being small, you can’t invent more people, money, knowledge or time out of thin air. You have to be crafty (as much as possible).

    The reasoning behind those externally required needs? The improvement of the health and well-being of an entire healthcare system, and ultimately, an entire nation… I hope.

  • “The reasoning behind those externally required needs? The improvement of the health and well-being of an entire healthcare system, and ultimately, an entire nation… I hope.”

    I think this is what we all hope for.

  • Think about all this stuff from a doctor’s perspective and it’s easy to agree that $24/day over 5 years isn’t worth the frustration of dealing with meaningless busywork of inputting all the crap that some government committee mistakenly thinks it’s important to have in a patients record.

  • That, Dr. West, is the grave reality of this “exercise”.

    The other reality is, like eRX, what is now an incentive will eventually become a penalty.

    As Anthony mentioned, the greater good is the intention, just like HIPAA. Just like seat belts & air bags.
    Heck, even the 3rd tail light – if you are a car guy you’ll remember how the car press went ape over the “out of control requirement”. Over the years, these things have been made to work.

    People, though, don’t like to be told what to do.

    Even though @John feels everyone involved should understand they will have requirements if they want a check…that just isn’t reality.

    HIPAA – a federal requirement – blown off by MOST private physicians. Sure they give it a little effort, but…

    ICD codes – gripe gripe.

    Even though there is money involved, Docs still don’t like being told what to do…that is reality.

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