As the long and winding river that is EHR certification rolls along, CCHIT recently opened up its latest iteration of testing to the public. The two new offerings are “CCHIT 2011 Comprehensive” Certification and, in line with what is known today about “meaningful use,” Preliminary ARRA 2011 Certification. To drill down on the distinction between these two programs, and to learn more about CCHIT’s progress overall, HCI Editor-in-Chief Anthony Guerra talked with CCHIT Chair Mark Leavitt.
GUERRA: Preliminary ARRA lowers the bar and leaves room for innovation in the marketplace, but doesn’t that mean there was a problem with the criteria being too proscriptive?
LEAVITT: No, because certification was voluntary before. When certification was voluntary, the issue was resolved by simply choosing to ignore us. The CIO of an advanced hospital was free to ignore us, and a vendor was free to ignore us. We were just there for those who said, “I think you could be helpful.”
ARRA changed that by making it – if not mandatory – at least pretty punitive not to adopt certified EHR technology. We didn’t ask for this, ARRA just happened to all of us, so we suddenly found ourselves on a bigger playing field with higher stakes. We had to figure out how to meet this higher responsibility, and since this is now not a purely voluntary matter, we were going to have to deal with that.
The option of site certification is needed as well. Because, for example, let’s say you have a sophisticated organization and they built their own EHR, or maybe they started with some products, but they modified them. Some of it maybe they built, some of it originated with the product. Under the site certification, it doesn’t matter where you got it. We’ll look at in place, and if it meets the standards, it gets certified. And we’ll find a way to do it at a lower cost for smaller organizations using the sliding scale, by simplifying the testing.
GUERRA: So Preliminary ARRA matches what you think HHS certification will be.
LEAVITT: Yes, and it has the standards in the meaningful use matrix. The standards came out of the Standards Committee; the meaningful use matrix came out of the Policy Committee. It uses those and nothing else. It does not go beyond what they’ve published. It is in their criteria. We’re just a testing organization for those.
GUERRA: And you feel comfortable reading the tea leaves that it’s pretty close to what’s actually going to come through.
LEAVITT: I feel pretty comfortable what will be final will not be more rigorous.
GUERRA: It’s been an interesting process, hasn’t it? People are working towards a goal as the goal is being defined – isn’t that difficult in theory?
LEAVITT: That happens in life and in business all the time.
GUERRA: It’s certainly not a best practice.
LEAVITT: Well, you know, I think that’s just life. I mean, we go to college before we know what we want to do when we’re finished. And we go to medical school before we decide if we’re going to specialize, and we start a business often not really realizing what the product is going to end up being. So I think that’s actually reality, and to assume everything would stand still is not.
Now, regarding the effects of ARRA, it’s interesting. First of all, it had an effect on us in that we had an explosion of applications for the 2008 program come in at the last minute, literally in the last week. After that, we’ve actually seen a slowdown in applications of electronic health records. A lot of vendors are saying they are stalled and frozen now because the government says, “We’re working on this, and we’re defining how you’re going to get paid and all of that, but we’re not ready yet.” And that basically freezes decisions. That’s not a good thing. We’re actually hearing from vendors that are at risk of going under because of that. So the stimulus act, because of the delays involved in implementing it, has had a paradoxical effect of slowing adoption.
Since our mission is to accelerate adoption, we couldn’t just stand by and say, “Sorry, we can’t do anything until they’ve finished their work.” That’s just not responsible. So whatever the small risks are about the standards being a little different, I think they’re much smaller than the risk of standing still, first of all, while having the market stall for a year and then having not enough time to properly implement when the products finally get certified and become available.
GUERRA: What do you think your standing is with small physician groups or with specialists? Do you need to do more outreach?
LEAVITT: We’re going to do more; we have done it mainly through associations and that’s been very successful. We’re going through associations like the American College of Physicians or the American Heart Association or American College of Cardiology. We’ve worked very well through the physician organizations, but reaching the physicians as individuals is very challenging.
GUERRA: Some people are not huge fans of CCHIT because of the evolution of the organization, the past ties with HIMSS, the fact that there are CCHIT trustees from the vendor community. How much more difficult has that made your work?
LEAVITT: Well, first of all, I think it’s understandable given the way the stakes were raised when the law was passed. The general United States taxpayer couldn’t care less about our existence before ARRA. Now, the United States taxpayer has money on the line for these incentive programs, and if we’re one of the organizations involved in saying whether a doctor or hospital gets the money or not, we have accountability literally to the U.S. taxpayer. So when the stakes changed, I think you’d have to expect the scrutiny to be elevated. I think that’s just life. I would say that those who have suggested that vendors should be completely excluded from our activities, for example, are wrong.
My feeling is if you’re trying to build consensus to solve a problem and reach a fair compromise between groups with conflicting interests and demands, you do it with everybody at the table, you don’t exclude one. Now, we do exclude vendors, as I explained earlier, from our jury panels. Anyone who is also a vendor can’t be looking at products and saying whether they pass or fail. But when you’re trying to decide what a reasonable leap forward in standards is or what’s a reasonable amount of functionality to require – you want everybody at the table.
So I don’t agree with people saying, “No, no, no, you shouldn’t have vendors there.” Well, you could equally say, “No, you shouldn’t have providers there because they want too much. They want more than can be afforded.” You can say, “You shouldn’t have government there because government shouldn’t be involved in healthcare.”
It doesn’t produce a consensus decision that people can trust when you exclude parties in the conversation. As long as there isn’t unfair influence and there isn’t an inappropriate dominance, it’s fine. We’ve gone out of our way to make sure there isn’t such dominance basically by limiting the number of seats for any one stakeholder group. We limited the number of volunteers on any one work group. We limit the number of commissioners who are vendors, the number of trustees who are involved in any way with the vendor community, just like we make sure there is a balance among the other types of stakeholders.
So I think we’ve done what matters to address that, all the procedural things that we can do to address that. And I think when the accreditation process comes out, the models that we built and the processes we built will meet those accreditation requirements. I look forward to that, so the controversy can finally be put to rest.
GUERRA: During the Certification & Adoption Workgroup meeting (a sub-group of the Policy Committee) when you gave testimony, there was a fairly heated exchange between you and Brian Klepper (Principal at Health 2.0 Advisors). Did you think his testimony was fair?
LEAVITT: It’s not up to me to comment on the operations of that committee. My concern is the operation of CCHIT, and we need to make sure we operate at the highest standards and that we have transparency. I believe I’ve done a good job of that. I think the results of our work to date reflect the acceptance we’ve had. When you look at the number of vendors that have been certified, when you look at the number of endorsements we have from providers, and when you look at the number of payers that have relied on CCHIT certification – and that includes the federal government with the Medicare EHR demo, many state governments that have programs for certified products, private sector payers, not just individual insurance plans but large consortia, like Bridges to Excellence that use CCHIT certification as part of their qualifications – all those results are really the strongest evidence of our work; not something I say, or something someone else says.
GUERRA: Well, it did get quite heated and you did say you were being attacked personally and that you resented it. I’ve read some blog posts you’ve written and others your critics have written and it’s been pretty contentious at times – was there ever a point at which you thought of resigning?
LEAVITT: The fact of the matter is that blogs run the gamut between really fine thinking, like John Halamka’s, and non-factual conspiracy theory type of stuff. So I think reading the blogs is the wrong way to figure out what is going on in health IT, unless you’re able to discriminate between the knowledgeable writer and fluff.
I don’t think what goes on in blogs is really a very good way to advance health IT right now. I think we need to look at the federal government’s movements, the related movements by the providers, and look to some leaders who give us a positive direction to move in.
GUERRA: I would imagine you’ve been spending a lot of time on a plane. You’ve appeared at a lot of conferences. You live in Oregon, but the CCHIT headquarters are in Chicago. It must be tiring.
LEAVITT: Well, I did earn my 100,000 mile flight status several years in a row. But I didn’t this year, and I’m proud that I was able to fly under 100,000 miles for the past year or two.
GUERRA: How much time do you get to spend in Oregon, at home?
LEAVITT: I don’t work in an office when I’m not on a trip. I’m working from my home office. So I think it balances out nicely.
GUERRA: The CCHIT site says you have 23 paid staffers, but in terms of the names that are listed, it’s just you and Alisa. It would be nice to know more people behind the organization. Any plans to get more names out there?
LEAVITT: That’s a good suggestion. I think early on, when we had about six to eight people working for us, we listed all of them. Somewhere along the line we must have stopped doing that, but I think it’s a very good idea.
We have a handful of contractors, so they’re not all employees. When we count the 22 or 23, whatever the number is, they’re not all full-time employees, but I think it might be nice to put some of their bios up there too. I don’t want anyone to think that most of the work in the organization is done by just myself, or myself and Alisa. Most of the work is done by the volunteers and the staff. I’m really just the spokesperson. So I think that’s a great suggestion. They’re very serious, very capable people, and they’ve done a great job.
GUERRA: What would be your advice to the industry as it pertains to certification and achieving meaningful use?
LEAVITT: My advice to anyone in healthcare who has not adopted health IT is that they need to move forward now. If they wait until the last minute, they’re going to have a lot of challenges. So I hope that nobody is going to wait until the penalties kick in and then decide, “Gee, the penalties are here, we’re going to have to scramble and do something real quick.” It’s a change that has to happen. There is now some federal incentive money behind it. And it’s really time to move forward.