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What does this mean for current non-certified EMR vendors? It will mean that unless they are a "certified" EMR, their physician customers will have to pass on the significant incentives and accept the penalites that are coming.
All EMRs are currently uncertified because there are no certifying criteria for the incentives. If you or anyone can enumerate the criteria, I would be most grateful. Trouble is, nobody knows the criteria because there will be a process to come up with them. A main point of contention, you can bet, will be on how inclusive or exclusive the criteria should be.
Regardless, the criteria will be promulgated sometime in the future. If the government wishes to have < 5% of physicians with a certified EMR, then they can simply regurgitate the current criteria found with CCHIT......but so far, those criteria have not worked well, and so I think we can safely assume that usablity and interoperability will be a more major concern.
You are correct, all EMRs are currently uncertified in terms of the incentives. This is because the definition of "certified" has not been fully clarified (in terms of the Stimulus Bill), though it will by the end of the year. However, for vendors to ignore what is happening is detrimental to their continued survival as a profitable entity.
Check out this thread where I ran the numbers- http://www.emrupdate.com/forums/t/8923.aspx?PageIndex=2
Al
Al Borges, M.D.
Al,
With all due respect, I can't see that 200K figure as being too real. Anyway, physicians have a choice, buy an EMR that makes sense for your practice or not. Not sure what the real issue is here. I have worked on both the provider and vendor side and have sympathy for them both.
By ADRIAN GROPPER MD
http://www.thehealthcareblog.com/the_health_care_blog/2009/03/why-and-how-secretary-sebelius-should-avoid-a-network-monopoly.html
This is a very nice article expounding upon how CCHIT should be utilized. I believe the Al could see eye-to-eye with the author if this article.
Sadly, The CCHIT process is merely a specifications check or qualification of features, and is nearly useless regaring safety, efficacy and usability (a.k.a. "certification" does not preclude a Mission Hostile User Experience™). Worse, CCHIT has significant conflicts of interest with the HIT industry. On a more minor point, this organization can't even manage its books properly, failing to file its required reports and temporarily being dissolved, involuntarily.
This post from "scotsilv" contains misleading and erroneous statements. These issues have been thoroughly discussed and resolved over the past two weeks in numerous web postings. Not quite sure where the vindictive slant comes from.
EMRAdvocate wrote:
> This post from "scotsilv" contains misleading and erroneous statements. These issues have been thoroughly discussed and resolved over the past two weeks in numerous web postings. Not quite sure where the vindictive slant comes from.
How insulting. But not to me ...
The post from EMR Advocate contains statements I believe may be insulting to the the intelligence of EMRUpdate readers. What I wrote is supported in the simple facts that I obtained out of curiosity as a journalist blogger.
In the HC Renewal post I linked to, I placed documents on how this organization did not manage its business affairs properly and was involuntarily dissolved (see them at http://hcrenewal.blogspot.com/2009/02/cchit-dissolved-involuntarily-in-april.html). They came directly from the Illinois Secretary of State's Dept. of Business Services itself. As I wrote, I consider these "a more minor point", although not inspiring my confidence in an organization "certifying" virtual medical devices that affect patient care - and patient lives.
As in the documents, we find that on Dec. 28, 2006, Articles of Merger or Consolidation were filed with the Illinois Secretary of State, Dept. of Business Services to merge "CCHIT, NFP" (an Illinois Corp). with "Certification Commission for Healthcare Information Technology, Inc.", a Delaware Corporation. The name of the surviving corporation was CCHIT, NFP, to be governed by the laws of Illinois and called "Certification Commission for Healthcare Information Technology."
Also from those documents, on April 11,2008:
"Certification Commission for Healthcare Information Technology, being a corporation organized under the laws of the State of Illinois relating to Domestic Corporations, has failed to file an annual report as required by the provisions of "General Not for Profit Corporation Act" of the State of Illinois, in force January 1, A.D. 1987, and all acts amendatory thererof; AND WHEREAS, said acts provided that upon failure to file an annual report, the Secretary of State shall dissolve the corporation."
If the Secretary of State of Illinois has the facts incorrect, I would like to hear about it. That is possible, but the personnel in the Dept. of Business Services informed me their database and documents were correct.
I also noted that if a physician lets his or her license lap and continues operations, it is in many jurisdictions a felony: An individual who practices or holds himself out as practicing a health profession subject to regulation without a license or registration or under a suspended, revoked, lapsed, void, or fraudulently obtained license or registration, or outside the provisions of a limited license or registration, or who uses as his own the license or registration of another person, is guilty of a felony.
An individual who practices or holds himself out as practicing a health profession subject to regulation without a license or registration or under a suspended, revoked, lapsed, void, or fraudulently obtained license or registration, or outside the provisions of a limited license or registration, or who uses as his own the license or registration of another person, is guilty of a felony.
On safety, efficacy and usability, CCHIT itself makes these claims. From Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems, Harvard Journal of Law & Technology 2008 vol. 22, No. 1, by Hoffman and Podgurski, p. 133-4:
"CCHIT, in fact, recognizes some of its own limitations. Its Certification Handbook states: Our criteria at this point can only represent broad, basic capabilities, and . . . these may prove insufficient for some practice specialties, or may be inappropriate or excessive for others; . . . our criteria do not assess product usability, implementation service, product maintenance, technical and application support; and other facts."
The issue of conflicts of interest can be seen at CCHIT's own web pages on its key personnel, at http://www.cchit.org/about/organization/commission/index.asp, some of whom work for and thereby have fiduciary responsibilities and loyalties to their employers. This is a common theme at HC Renewal, whose authors have no such conflicts of interest. Whether one considers such arrangements acceptable for a certifying agency or not is a matter of opinion, but the conflict of interest exists as a fact.
> Not quite sure where the vindictive slant comes from.
"Vindictive?" "Slant?" While it's not usually worth the time for intelligent, responsible people to respond to ad hominem and other fallacious argumentation styles, I will do so here:
EMR Advocate employs the common logical fallacy known as "ad hominem attack", whose description from the Nizkor Project pages I reproduce below. This type of attack is often used against minorities and those holding minority or unpopular (to some) opinions.http://www.nizkor.org/features/fallacies/ad-hominem.html
Translated from Latin to English, "Ad Hominem" means "against the man" or "against the person."
An Ad Hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting the claim or argument. Typically, this fallacy involves two steps. First, an attack against the character of person making the claim, her circumstances, or her actions is made (or the character, circumstances, or actions of the person reporting the claim). Second, this attack is taken to be evidence against the claim or argument the person in question is making (or presenting). This type of "argument" has the following form:
The reason why an Ad Hominem (of any kind) is a fallacy is that the character, circumstances, or actions of a person do not (in most cases) have a bearing on the truth or falsity of the claim being made (or the quality of the argument being made).
Now, if someone could offer substantive critique of my post and back it up with evidence that a college professor such as myself would like to see from students, and without spinning like a neutron star, I'd be happy to consider their information.
Also, please don't insult my intelligence again, or I will employ even more aggressive dissection of the information presented and its logical fallacies, somewhat like I did in dissecting the cranial nerves in Gross Anatomy lab with great precision.
Finally, "vindictive" "Shylock" that I am, I should charge EMRAdvocate for my time in composing this message to clarify my post..
-- SS
I think that he got it pretty much correctly. Where did he error? Let's take some of his statements-
"The CCHIT process is merely a specifications check or qualification of features, and is nearly useless regaring safety, efficacy and usability"
That's TRUE- CCHIT doesn't measure usability. In fact, most c-EHR systems are quite difficult to use. Just check out the aafp annual review of physician members and you'll see the likes of Touchworks, Centricity, Cerner, NextGen, and Misys on the bottom of the heap in terms of usability. URL: http://www.aafp.org/fpm/20080200/25user.html
"a.k.a. "certification" does not preclude a Mission Hostile User Experience™)."
That's TRUE too! In fact, the more complicated the EMR, the higher the chance of installation failures or eventual deinstallation, all of which can total more than 40%.
"Worse, CCHIT has significant conflicts of interest with the HIT industry."
TRUE again! CCHIT was set up by HIMSS/EHRA vendor group and is a certification process that has dessimated the competition by giving preference to "enterprise" EMRs. It's run by vendor representatives and we've shown here in several threads that HIMSS/EHRA have bought out Obama and other elected officials.
"On a more minor point, this organization can't even manage its books properly, failing to file its required reports and temporarily being dissolved, involuntarily."
TRUE again! You can read about it in Histalk- URL: http://histalk2.com/ (then do a search for "CCHIT")
YOU: "With all due respect, I can't see that 200K figure as being too real."
That's because you haven't had to live with the paltry Medicare payments like I have for over 20 years. These numbers are real, and for those docs that do try to got the c-EHR route, they will need to jot down their income losses down to the penny so as to become aware of the losses that they are sustaining quickly. Eventually they'll come to realize that my figures aren't all that off the mark. Now- this is IF they don't go through an installation failure (chances: 20-40% with a c-EHR) or an eventual deinstallation (chances: 8% with a c-EHR)... where you lose your $30000.00 right off the bat without any Medicare payment since you'd lack the "significant use" criteria.
Hey Al,
Care to comment on Jim Tate's article on HIS TAlk. I have yet to see anywhere on CMS stating that physicians MUST purchase CCHIT certified EMR systems to receive bonus or otherwise incure penalties.? I'm trying to asses as to where is Jim Tate acquiring all his information from. Where does it state in the CMS mandate guidlines in regards to EMR mandatory CCHIT certification?
http://www.histalkpractice.com/2009/01/31/an-hit-moment-with-jim-tate/
An HIT Moment with ... is a quick interview with someone we find interesting. Jim Tate is president and eHealth consultant at EMR Advocate, LLC.
What’s the best way to use federal dollars to get physicians to use EMRs in ways that benefit patients?
The current Federal incentive program for e-prescribing that began January 1, 2009 is a good model to also encourage providers to document patient care in an electronic record. I would suggest that starting July 1, 2009 providers would be given a bonus (5%?) for every Medicare/Medicaid charge that was documented in a CCHIT-certified EMR. Reduce that bonus every year by 2% until it becomes a penalty (-5%).
The process would play out over five years and the requirement that the EHRs are CCHIT-certified would guarantee that interoperability would be a part of the adoption wave.
What tips can you offer physician practices for selecting and contracting for EMRs?
You really need to protect yourself and stay in the driver’s seat and do the things that will lead to a smoother implementation that will occur on your terms.
Assuming physicians buy systems that are CCHIT-certified and therefore theoretically interoperable, how will they actually interoperate for patient benefit?
Interoperability can occur to benefit patients in ways that could never have been possible with paper records. The ability to generate, receive, and display CCD (Continuity of Care Document) type files is part of CCHIT’s 2008 Ambulatory criteria. This ability to generate and receive a file composed of a patient’s demographic and clinical information is a good first step to ensure that information can be shared between physicians and different EHR systems.
Another standard of CCHIT certified systems is the requirement that the EHR must be able to receive laboratory results in a discrete format directly into the patient’s electronic medical record. The provider is notified of the presence of the lab result by the system, not by the nurse. The results can be compared, graphed and then messaged to the nurse for appropriate resolution. This leads to fewer steps in the workflow, fewer lost labs and increased efficiency in the process.
Debate continues on whether today’s EMRs are good enough to be worth massive federal investment. Where do they fall short and what should vendors be doing?
It is apparent that Obama is preparing a massive federal program to accelerate the adoption of health information technology. Currently we are only at the early stages of interoperability and the subsequent ability to exchange and gather data. The capability to exchange and congregate this discrete data must be aggressively expanded to bring added clinical value. Also, the user interfaces of many EHRs are cluttered due to the high level of functionality. Design work needs to be done to make these systems easier for the users.
What technologies are available today that can help physician practices, but are less expensive and easier to implement than full-blown EMRs and practice management systems?
As a project manager for numerous EMR implementations in both the US and China, I saw the great risk of trying to immediately adopt all possible functionalities in an EHR. We called it the “Big Bang”. It was good for the vendor, usually not so good for the providers.
In many clinics, the workflow has been created over years, sometime decades. To change everything at once is incredibly stressful and can lead to the failure of the EHR being embraced by the users. To implement in a modular fashion has the benefit of reducing stress and also minimizing the loss of productivity that usually takes place with the “Big Bang”.
Messaging, e-prescribing, e-faxing and receiving discrete lab results are all good examples of “first steps” that can get the provider into the electronic arena.
"Interoperability can occur to benefit patients in ways that could never have been possible with paper records. The ability to generate, receive, and display CCD (Continuity of Care Document) type files is part of CCHIT’s 2008 Ambulatory criteria. This ability to generate and receive a file composed of a patient’s demographic and clinical information is a good first step to ensure that information can be shared between physicians and different EHR systems.
Another standard of CCHIT certified systems is the requirement that the EHR must be able to receive laboratory results in a discrete format directly into the patient’s electronic medical record. The provider is notified of the presence of the lab result by the system, not by the nurse. The results can be compared, graphed and then messaged to the nurse for appropriate resolution. This leads to fewer steps in the workflow, fewer lost labs and increased efficiency in the process."
Well Medtuity did this long before it became CCHIT certification criteria. So tell me again, what is the advantage with CCHIT? And we did CCR testing with CCR files produced by a variety of vendors and they were of such poor quality in their content, that they were hardly usable. Is that a criteria of CCHIT too?
They asking for CCD and not CCR.
Not sure though if it's going to be any different
Graham http://www.synapse-ehr.com/ Synapse - the EMR for the superior physicianhttp://www.onhealthtech.com/Health Tech Discussion Board
mchasemd: Another standard of CCHIT certified systems is the requirement that the EHR must be able to receive laboratory results in a discrete format directly into the patient’s electronic medical record. The provider is notified of the presence of the lab result by the system, not by the nurse. The results can be compared, graphed and then messaged to the nurse for appropriate resolution. This leads to fewer steps in the workflow, fewer lost labs and increased efficiency in the process." Well Medtuity did this long before it became CCHIT certification criteria. So tell me again, what is the advantage with CCHIT?
Well Medtuity did this long before it became CCHIT certification criteria. So tell me again, what is the advantage with CCHIT?
About laboratory results.... What does that have to do with CCHIT as well? You MUST certify with labs before they turn on any interface whether you are CCHIT certified or not. You have to run through all the LabCorp/Quest test cases and provide screen shots and paper requisition samples. The labs don't charge you for that. So why pay the thousands of dollars to certify lab order/results to the CCHIT folks?
Margalit
Margalit Gur-Arie
On Healthcare TechnologyHealth Tech & Policy Blog
Hi TIm:
Ok- here's my response-
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I find disheartening that our current president and now software consultants have the guts to advocate how and what physicians in private practice earn. Who the hell is Mr. Tate to advocate a 5% penalty for docs that refuse to use the very c-EHR systems that he advocates for? This is tantamount to having a career envious used car salesman suggesting to the current administration how to hurt physicians. This must be what Obama considers “change” (for the worse that is). How low can we go?
The reasons that 96% of physicians despise certified electronic health records (c-EHR) systems and thus are not purchasing c-EHR are that:
1) Across-the-board do not offer a ROI. c-EHR systems are expensive, increase overall costs, and destroy an office’s work flow. 2) c-EHR systems have not been shown to decrease errors, and on the contrary, have been shown to INCREASE them, introducing 22 new errors in one study. 3) Purchasing a CCHIT-certified EHR is associated with a 20-40% installation failure and with an 8% deinstallation rate thereafter. 4) CCHIT-certified EHR systems are not yet interoperable and in general do not allow data input like how physicians are used to- dictation, typing, inking. 5) c-EHR systems have not been demonstrated to increase quality in large, non-vendor associated prospective randomized studies. 6) Doctors generally consider most CCHIT features “bloat”. 7) Doctors hate e-prescribing and CPOE.
Let’s say that a physician who sees $100000.00/year worth of Medicare billings gets punished 5% for seeing Medicare patients without a c-EHR, and compare his situation over 5 years to a foolish physician who has capitulated to this atrocity. Let’s do the math:
– The non-complying physician will lose $5000 a year x 5 years for a total loss of $25000.00 – The foolish complying physician will lose 10% a year for maintenance fees and other “consultant” fees to keep his system running, AND he’ll lose another 15% to workflow losses and another 15% to the costs of entering in the data as well as reporting P4P for a total 40% loss per year, or (5 x $40000) - $44000 = $156000.00 total losses.
Note: The above figures are **conservative** and could be higher. Also, they don’t take into consideration the fact that the complying physician could be told that he didn’t use the c-EHR significantly thus voiding his earmark. It also doesn’t take into account losses associated with installation failures or deinstallations.
So the physicians without c-EHR systems will come out ahead after 5 years by a factor of 6!
What will really happen is that Medicare will end up failing faster than planned when physicians end up running for the exit door and either opt out completely or become nonparticipating providers. This will turn Medicare into an empty shell where there simply won’t be enough physicians to care for the massive and still growing population of the elderly.
I think the Raison d'être for CCHIT is "industry self protection" from outside scrutiny.
I would have no issues with CCHIT if it, and others such as hospital executives and government, didn't take it so seriously, but as a marketer, and if it didn't use the loaded term "certification" as opposed to the more accurate "features qualification."
Let me explain.
Most of these HIT players would never survive the scrutiny that the pharma industry does regarding IT. In pharma, a clinical trials information system (far less complex than an EHR, and with less immediate impact on patients) is subject to rigorous FDA validation, surprise inspections, etc.
In the EHR industry, there are no such validation and regulation processes. It's entirely unregulated. Hospitals are by contract not able to divulge defects in these products to other organizations. Physicians are considered "learned intermediaries" between the IT and the patient, so are liable in court for errors that might indeed be caused by user fatigue and cognitive overload from clinical IT with a poor user experience, or outright IT malfunction Imagine that in the aircraft industry.
In addition, so are HIT's workers and leaders unregulated. Anyone can "hang out a shingle" as an EMR expert, and believe me, they do. The HIT industry is like the Wild West of medicine where snake oil salesmen roamed the plains, or like medicine before the days of the Flexner Report. The incompetence level of some of the hospital CIO's and IT vendor leaders I've had the displeasure to meet is stunning. See my academic website on HIT difficulties.
This freedom from scrutiny and accountability has been becoming more and more controversial and publicized. I believe the industry in a half baked attempt to stave off regulation concocted the idea of a "certification commission" that was akin to the "professor who gives everyone an A."
Looks good, not too painful, helps call off the dogs of scrutiny and accountability.
As someone else said, physicians are not Luddites nor technophobes. In fact they are quite smart, with excellent bullshit detectors when it comes to patient care. They resist CCHIT and "certified HIT" for that reason.