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Heck with "Meaningful Use"- It's "Certified EHR Technology" I'm worrying about

May 18, 2009
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I confess that I’m coming down with a serious case of Meaningful Use Fatigue.
Since the ARRA included that phrase as a condition for receiving EMR incentive payments, the industry has been parsing those two words like a French literary deconstructionist. Google will give you about 9.1 million hits on “meaningful use”.

All the angst reminds me of those people back in school who were always obsessing over what was going to be on the test. Why not just learn the material? The test will work itself out.

Likewise, it seems to me that the best advice for providers to follow today would be:

1. Get a system that works

2. Use like it’s intended to be used

The end result will be real benefits for you and your patients- AND you’ll almost certainly qualify for a good chunk of incentive money.

HOWEVER…

The section of the act that addresses incentives under the Medicare program is titled “INCENTIVES FOR ADOPTION AND MEANINGFUL USE OF CERTIFIED EHR TECHNOLOGY.” What is “Certified EHR Technology”?

For the last few years it’s meant only one thing- CCHIT blessing.

I appreciate the role that CCHIT has played. As a voluntary certification body it has satisfied a very valuable need for organizations who are selecting a system; you had at least SOME independent confirmation that the system you were banking on was functional.

CCHIT’s approach to certification standards has been to influence system development by annually raising the bar. The exact same “certified” system that you contracted for last year, and are still going to be implementing into next year, may not be certified against this year’s standard.

The process of certification that the vendors have to navigate is onerous enough that they have to make a business decision as to whether it’s worth recertifying the superseded versions of their products against the new standards. With the relatively long development and upgrade cycles that are common in healthcare IT, it’s not at all unusual for vendors to have significant numbers of customers spread across three or even four versions of their product.

Let me give you a personal illustration…

We are one of those organizations that one would think is perfectly poised to leverage our status as early adopters of EMR technology into some serious stimulus money. We bought a big, capable system from one of the leading vendors, we’ve got a mature implementation, and we’re using it pretty darn meaningfully.

Our vendor was a big supporter of the CCHIT initiative and our product was one of the first to get certified.

But if you look at CCHIT’s web site, the version of the product we’re running is NOT listed among those with current certification.

It’s not that we’ve been negligent in keeping up with upgrades. We did two point upgrades in the last few months.

The issue we’ve faced is that the vendor is in the process of a major, transformational upgrade cycle that’s been painful for them and many of their customers. They’ve focused so much effort on the new version that they haven’t bothered tweaking the previous version to keep up with CCHIT’s evolving standard, or to run the gauntlet of testing and certification for a product that they want to have everyone off of in the next 12 months. (As if.)

Now, does it hurt anything that my EMR version hasn’t gotten official blessing against the latest list of requirements? Nope. That certification is informational, advisory, consultative.

If it meant the difference in collecting $6Million in stimulus money? THAT would be a problem.

(Lest you think I’m just grinding my own axe here, we are starting our upgrade initiative now and should be safely back in the “certified” camp before the year is out. For now, at least.)

I attended Mark Leavitt’s session at HIMSS where he discussed what he expected CCHIT’s role to be in the certification process. He made some interesting observations.

First, he pointed out that the final call on what “certified EHR technology” means will be up to the new Standards Committee. For what it’s worth, they had their first meeting last week. (Transcript)

Secondly, he indicated that he wasn’t sure that CCHIT would be the only group providing input to the Committee. That sounds like what he should be saying, but are there any other groups out there with enough experience and gravitas in the certification arena to displace CCHIT’s recommendations?

And finally, he suggested that he expects to present options to the Committee, who will need to pick from their menu of choices in such a way as to satisfy their policy goals and political expediency. (Though I’m pretty sure he didn’t say it quite that bluntly.)

The point is that the committee will need to think about what they want to incentivize.

Is the goal to encourage utilization of SOME kind of HIT, to lay the groundwork of finally getting rid of paper-based records? Then they need to set the bar lower and go for the big tent approach.

If, on the other hand, they want to encourage specific functionality (like interoperability, for example), they will need to make sure systems satisfy that functionality to get certified. A lot of companies, and their customers, could get left out in the cold.

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Excellent, excellent post, Mark. You really highlight the disconnect between real-word facts (vendor's moving from one version to the next and attempting to shepherd their customers along), with the fact that there will necessarily be a lag between when those products hit the market and whey (or if) they are ever certified. With vendors constantly upgrading and CCHIT constantly raising the bar on certification requirements, the industry will be in an unmanageable state of flux.

Not only is the existing process of certification flawed, but the current process for getting us to a future state is highly flawed. Check out the Washington Post article mentioned in other posts to understand why we are where we are.

All the concerns about "meaningful use" are a little silly. Congress was simply trying to say that "We're not going to reimburse you $45K for a system that you paid $25K for and aren't even using." And IMHO, you either are using your EMR, or you're not it's just not practical to use it for some patients or for some small part of the feature set.

As for CCHIT...It's no wonder healthcare is expensive in this country. Congress manages to use word processing software to write the laws of the land without the vendors having to spend $30K every year to certify that it does what it says it does. Why do EHR vendors have to do so?

I'm glad that you went with "Shakespeare character" as opposed to "Latin heart throb"...

Making a decision on how quickly to pull the trigger on a system decision is a quandry.

IF the incentives work as designed, a lot of customers will be scrambling to get a system installed. If you wait too long, I'm concerned that neither the vendors nor the customers will have the people to get the applications installed and usable- meaningfully or otherwise.

But if you rush to judgment and pick the wrong system you're pretty much out of luck too.

You make the best decision you can, pay your money and take your chances.

"Certified Product" a Moving Target?

Excellent points by both Mark and Anthony (Shakespeare character?). We've known all along that "meaningful use" will be a moving target-thats unsettling enough. Will "certified product" also be dynamic going forward? No wonder practices are confused.

Why are so many advocating that practices should purchase EMR's NOW and get working on implementation to get in on "early" stimulus incentives? Those physicians who have not found compelling reason up to this point to deploy EMR should rush out and get one NOW because of Stimulus Bill (ARRA) incentives? Where's the logic? It almost has the feeling that its being pushed too hard before all facts are known. Who benefits from that? Lets look at the facts:

1. The end EMR must be "certified"...but "certification" is not yet defined and what is known is largely focused on Primary Care providers. OK, but that leaves more than 50% of providers wondering a few things.

2. The incentives provide for up to $44,000 in reimbursement to physicians, but ONLY for those who are able to show proof of "meaningful use". The term "meaningful use" has only been vaguely defined, containing the three elements of electronic prescribing, interoperability and reporting on quality measures. Again, while vague, the focus is still on Primary Care. How much confidence can specialists have about what "meaningful use" will be for them? And the $44,000 will only be a PARTIAL reimbursement, over the five years.

3. Providers and practices must pay out 100% of the cost for any such system to purchase it NOW. Whatever the cost is. The Stimulus Bill will reimburse up to $44,000, but over FIVE YEARS of proving that elusive "meaningful use" standard, which the committees at work have said will be "an evolving standard". Can providers, especially the specialists, have confidence going forward, to pay out 100% of the cost NOW...based on that?

4. The "interoperability" provision in "meaningful use" will depend, it seems, on the existence of an HIE network and standards-which are not in place yet. Are physicians to ASSUME that the software and the networks-two highly complex and prone to early-stage "bugs" will all come together and work perfectly so that "meaningful use" can be shown sometime well after they've paid for the system?

5. Then there's the subject of productivity. MANY physicians have not adopted EMR up to this point, NOT strictly because of financial concerns, but because of the productivity impact EMR would have on their practice. This is especially true of specialists and any high-volume providers. Physicians have resisted being made into data-entry clerks in front of their patients, like most EMR products require. Stimulus incentives do not solve this problem at all.

There are alternatives to traditional EMR and the inherent issues EMR has long had. Physicians will adopt technology that helps them provide better care if it doesn't mean slowing them down or force them into making tedious data entry in multiple screens and menus for each patient. Hybrid EMR has come to be the answer for specialists and high-volume providers. The "certification" process should be expanded to include products designed for these high-volume providers whose time for office visits is limited by the hours spent in surgery or outpatient centers. With hybrid EMR, productivity loss is not a by-product or trade off of adoption.

Could that be the reason why many EMR vendors-including one in particular urging "The Time Is NOW"- are the ones pushing so hard? If "certification" is going to be a moving standard, it needs to embrace "meaningful use" for ALL medical specialties for incentives. This is not in place yet. So if practices rush out and purchase an EMR before all the facts are known, the vendors probably will be the one's benefitting most.

It is hard to disagree with any of the comments here but I'd like to offer yet another concern. Everyone is rightfully concerned with "meaningful use" as the ultimate definition will determine what kind of return we get on this investment. But everyone seems to be focusing on "meaningful" and no one is talking about "use". At this point, I would focus on "use" of a certified EHR. I hope that "certified" focuses more on the ability of data to come into and out of a system and not so much on specific features. That can and should come once we have established "use". In fact, I would prefer to see money being spent more on building a national infrastructure to exchange data, allowing EMRs to become more like web browsers able to access the data than heavy applications with long development and implementation cycles.

Mark,
Great post. You'll see from my post today (Phasers On Stun), summarizing my presentation last week, that we've reached the same conclusion. The options laid out there were the consensus of a few dozen industry veterans.

You'll see in my link a page from Wikipedia on Test-driven development, with the heading "Teaching to the test." That's another real hazard of this process.

Thanks again for a thoughtful post.

Meaningful use? The VA's VistA is used more than any other meaningfully. So, why are so few institutions using commercial versions of a proven, meaningfully used VistA system? My impression is quirky certification criteria. Commercial versions of VistA are less expensive, faster to implementation and "meaningful use", and have high adoption and satisfaction rates with clinicians. Not to mention the VA's impressive improvements in care. 'Nuff said?

I do not think that CCHIT will provide the certification for ARRA...

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