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Hi everyone. I recently posted on The Health Care Blog an open letter to Dr. David Blumenthal, the new National Coordinator for Health IT, on the pressing need not to let CCHIT mandate the definition of ‘certified EHR’ when crafting the new HITECH policies.
In my opinion, the CCHIT model is fatally flawed and will prevent the emergence of simple, helpful, efficient and inexpensive EHR software. I believe that all the hard work now being done to reshape our healthcare IT system will be moot if the CCHIT model prevails.
One thing I do not have a clear sense of is how many developers have not been able to effectively market their products because they are not CCHIT-certified. I also do not have a clear sense of the time and effort that developers have had to invest, beyond the actual $30K fee, to achieve CCHIT certification.
My letter is posted on TheHealthCareBlog.com, which is widely read by persons shaping health care IT policy. If anyone would care to weigh in on these issues or on other ways that CCHIT certification has interfered with the usability of their products, here is the link:
(http://www.thehealthcareblog.com/the_health_care_blog/2009/06/an-open-letter-to-dr-david-blumenthal.html#more)
Thanks,
Rick
Rick Weinhaus, M.D.
Watertown, MA
Rick,
The first time I read the CCHIT certification requirements, I was struck with the disconnect between those writing the requirements and those looking for an EMR. For example, to certify required some pediatric specific functionality which would not be used by most practitioners.
Why would such criteria be included? CCHIT smacked of exclusionary practices-- promulgate criteria already developed by the big EMRs in hopes of excluding the startups, even if those criteria had little to do with actual need.
Over the last 5 years or so, I have heard the term "interoperability" used in conjunction with CCHIT. Nothing could be further from the truth. A useful standard was developed for trading information among EMR users (the CCR) but not utiliized by CCHIT, for example. Trading information among users was not a priority, and if it had been, CCHIT would have taken the CCR seriously.
The price of certification alone is exclusionary. If it truly cost $35,000 to test a product for compliance, it would suggest that it takes man-months, not hours to accomplish. Certainly a tester spending months surveying a product for compliance could test usability. Instead, this high figure is not designed to allow thorough testing, but to be exclusionary.
The large EMR vendors are essentially selling themselves to the devil (a loss to capitalist system) in hopes of eating at the government trough. And they certainly don't want competition at the trough. In short, if they cannot cut out the small vendors through obviously excellent product offerings, then why not do it by fiat. Unfortunately, so many companies have become dependent upon the government for their existence, that it is becoming vogue for CEOs to join the cocaine party. When it was simply Lockheed Martin making defense items, it seemed fair enough. But no bid contracts, even in the guise of CCHIT fiats are really profitable.
Big business is not about altruism or even making customers happy. It's about getting paid the maximum amount....and if you cannot be paid maximally by customers who find the steep price tag little to pay comparied to the efficiencies produced, then you have to do it by rule. A painful lesson will be learned.
I am reminded of that old adage ... those who can do, those who can't - certify.
Graham http://www.synapse-ehr.com/ Synapse - the EMR for the superior physician
Matt and Graham,
Thanks for your comments.
Matt, would you have any interest in posting what you wrote above as a comment to my post on The Health Care Blog, so that it reaches a wider audience?
Here's another issue ... CCHIT proscribes certain functionality which vendors have to implement. But since they know the users won't have a bar of it, they also implement the ability to turn off that functionality! I've seen several vendors here post along these lines.
So, the functionality is built purely to pass the test scripts .. and then disabled in real use. This is the bizarre side effects where functionality is proscribed at a micro level.
But then the nature of certification logically leads to such outcomes. The certification authority to justify their existence has to create more and more "functional requirements" so as to be seen to be earning their fees, and remain relevant .. a variant of Parkinson's Law.
Rick:
Good job, but remember that GE pays part of Dr. Blumenthals salary (in the form of grants). President Obama is surrounded by "enterprise" EHR company vendor representatives, others being-
So HIMSS will lobby hard for the CCHIT criteria to be incorporated into HITECH. On a state level, there are numerous states trying to get the $2 billion going to the states out of the $19 billion HITECH carveout of the ARRA law. For example:
In the case of NJ, I did a thorough research into Assemblyman Conaway, the bills sponsor, a physician himself, for evidence of heavy lobbying by HIMSS, and there was tons of it which I reported here- http://www.emrupdate.com/forums/t/19877.aspx. I even found a HIMSS "contribution" in one of his annual financial statements! I wrote an article on this called "States to Obama: Give Us That HITECH Grant Money! " to be published in the July issue of MD Net Magazine.
As Graham and Matt have stated, CCHIT is all about stifling competition in the marketplace to a point that in 2006 I and other sent in FTC complaints- http://www.emrupdate.com/forums/p/7165/56115.aspx . I also found that this not-for-profit even lied to the IRS! Their first "incorporation papers" clearly stated that all profits were to be distributed to their founding (HIMSS) vendors, and their 8/2006 monthly meeting notes clearly stated that they were going to make a million dollars that year. They subsequently stopped doing monthly minute notes from 9/2006 to 11/2006 then on 12/2006 started producing very brief minute notes that continue to this day without any sort of detail. That month they also reincorporated CCHIT. (The incorporation papers and minute notes are downloadable from here- http://msofficeemrproject.com/Page3.htm , just look at PDF1 and PDF2 at the bottom.
I could go on about this CCHIT scam, but my wife is pulling on my ear... Thank you for publishing your open letter and I wish you the best of luck in getting through!
Al
Al Borges, M.D.
Graham,
In addition to the hundreds of unnecessary features and functions mandated by CCHIT, many of which are never used and which the clinician doesn’t even know about, there is another problem. Some of the CCHIT- required and features and functions are arguably harmful to patient care.
Off the top of my head, I think of how CCHIT mandates the Problem List be maintained.
It specifies that the EHR program be able to maintain a separate list for active problems and for inactive/resolved problems. CCHIT permits inactive/resolved problems to be grouped together. Presumably, a physician might only review the active problems when reviewing the electronic chart.
What about the diagnosis of lupus, currently inactive? For most patients and their physicians, the diagnosis of lupus continues to be a major issue, but lumping it with resolved problems (appendicitis for instance) means that another physician caring for the patient might overlook this critically important diagnosis.
What about the case of cancer in remission? It’s not active, and it’s also not inactive/resolved. It’s in remission. It’s still a very important piece of the patient record and the CCHIT requirements artificially force it into one category or the other.
Any other examples you can think of?
Al,
Thanks, I share your concerns. I did find it encouraging that Dr. Blumenthal wrote that many CCHIT-certified Ehrs were not user-friendly in his recent NEJM article.
I have no idea of whether my post will have any impact, but I feel so strongly about the usability issue that I want to try to get the message out before the new HIT Policy Committee decides what ‘certified-CCHIT’ means.
Did you see the reference in Histalk to the recommendations made by the Association of Medical Directors of Information Systems (AMDIS)?
http://histalk2.com/2009/06/27/monday-morning-update-62509/
Very interesting and similar to CCR except that they don’t even include CPOE out of concern for unintended consequences.
Al and everyone,
I went to letter from the Association of Medical Directors of Information Systems (AMDIS) to Dr. Blumenthal referenced above and the details of the letter are very different from the impression given by the summary.
While some of the suggestions seem good to me, (for instance, ‘meaningful use’ should be seen through the patient’s eyes), a careful reading of the rest of the letter reveals a commitment to CCHIT-certified systems.
AMDIS recommends:
Use only EHR systems that are considered “safe and effective” by a trusted authority.
and
. . . we recommend that the most important 2011 stretch goal for most physicians and hospitals will that physicians and staff become regular and appropriate users of those core EHR functionalities that are relatively easy to implement and use in EHR systems certified under the 2008 CCHIT criteria.
As I read the letter, the core recommendation is to have all physicians start to use a CCHIT-certified system on a regular and consistent basis, and then address issues of ‘meaningful use’ down the road.
rweinhaus:As I read the letter, the core recommendation is to have all physicians start to use a CCHIT-certified system on a regular and consistent basis, and then address issues of ‘meaningful use’ down the road.
Actually it reads as certified under the CCHIT 2008 criteria ... doesn't say certified by CCHIT.
And as Scott will say, there are no EHR systems that have been certified as "safe".
>>> As I read the letter, the core recommendation is to have all physicians start to use a CCHIT-certified system on a regular and consistent basis, and then address issues of ‘meaningful use’ down the road.
Why not just let them use whatever system that they feel comfortable with then put together a RHIO or HIE which can offer an interface to accomodate all disparate systems s.a. the Microsoft venerable ODBC which is now about 15 years old and comes free of charge with any license of MS Office?
Medicare, which will be going bankrupt by 2017, is now probably one of the worst payors in my area, sometimes sending back up to 30% of my billings due to trivial stuff. Medicaid, the insurance for the poor doesn't even pay the secondary 20%, and hasn't for the past 10 years. Many combination Medicare/Medicaid patients refuse to pay anything on their own. And now we have HITECH... Are doctors blind to the fact that this government-run-healthcare system is sinking? Helloooooo....
The secret, for those physicians that want to remain sane through all of this is to simply not take Medicare, or loosen up their participation. You instantly say "no" to penalties and other expensive, overhead consuming activities s.a. eRx, PQRI reporting, etc. In fact, if one partially participates, i.e. become a "participating nonparticipating provider", you get to charge 15% over Medicare's approved amount nullifying the up-to-5% penalties by a factor of 3 (immediately), you get to charge the patient up-front, and you slimline your Medicare roster to make room for less sick PPO/HMO patients without all the administrative hassle, or at least less of it. I talk more about that here: http://www.hcplive.com/mdnglive/articles/PC_passed_the_stimulus
Just tonight I discussed things with an oncology friend of mine who attending this year's ASCO convention. They impressed him with the need to go c-EHR by 2011 or be hit with multiple penalties and he thought that he would be breaking the law if he didn't comply. The guy was frightened out of his wits. He had no idea that HITECH was written completely by vendors (as stated by Glen Tullman, CEO of Allscripts, who is Obama's personal HIT consultant) who have paid/lobbied Obama into that position in which they, these very vendors, were literally were given the keys to the future of physician involvement in Medicare. It's like allowing bank robbers to set teh safety standards of banks.
He had no clue about the high failed installation rates, the high deinstallation rates, the true cost of "significantly using" a c-EHR ($300000.00 or more over 5 years). At ASCO (the American Society of Clinical Oncologists conference), there seemed to be a half dozen vendors catering to oncologists. The most expensive sold their wares for $250000.00 a license. I suspect that they were playing good cop/bad cop, manipulating the physicians in a way that quickly if one sees such a high price tag, then a $10000.00 cost up front with a 20% yearly fee doesn't seem very expensive, and might even consider that figure a "bargain". Sort of like my dermatology friend who was offered GE Centricity for $30000 up front or $500/mo for 5 years (with a mandatory no contract termination clause). You still end up spending the same amount of money... Why are physicians so stupid sometimes?
Frustrated in DC...
alborg: Why are physicians so stupid sometimes? Frustrated in DC...
Why are physicians so stupid sometimes?
Why is ASCO supporting this stuff? And all the other societies? Do you guys have absolutely no say in what your trade organizations do?
Margalit Gur-Arie
My brand new Blog: On Healthcare Technology
What it comes down to is that when you don't have to pay for a c-EHR system and you don't have to "signficantly use" it, then many in academia will go with the politically correct conventional wisdom. It is a shame that our medical societies are so out of synch with their membership.
It kind of reminds me of the news report that came out at http://www.theonion.com/content/news/report_98_percent_of_u_s_commuters titled: "Report: 98 Percent Of U.S. Commuters Favor Public Transportation For Others". Basically, it's a comic view about how it's human nature to be altruistic when it doesn't affect YOU. Then there is the affect of the power of big government on medical societies as well as the affect of HIMSS lobbying efforts.
Interestingly, it seems that some politicians are hearing the voices from the trenches. Check out how this Republican is highlighting my article as the way that physicians think- http://bertroche4congress.com/What_docs_are_thinking.html (He's a psychiatrist still in private practice, which is why he may be so understanding.)
The more I consider the recommendations of the letter from the Association of Medical Directors of Information Systems (AMDIS) to Dr. Blumenthal on ‘meaningful use’, the more disconcerting I find them.
Despite Dr. Blumenthal’s recent NEJM article where he stated that many CCHIT-certified EHRs “are neither user-friendly nor designed to meet HITECH’s ambitious goal improving quality and efficiency,” it appears that AMDIS is advocating widespread adoption, not meaningful use, of CCHIT-certified EHRs. AMDIS even coins the term ‘meaningful adoption’. (In the quotes below, all non-header bold type is mine).
RECOMMENDATION 3: Keep early (2011) objectives and measures of meaningful use sharply focused on demonstrated evidence of appropriate EHR data capture and sharing.
Our experience as physicians and clinical informatics leaders reinforces our sense that the first step in meaningful physician EHR use is “regular and appropriate use” for data capture and sharing . . . While AMDIS members also seek accelerated physician EHR adoption and meaningful use, we are mindful that this process typically follows a “crawl-walk-jog-run” progression, requiring cycles of training, practice and continuous improvement. These cycles cannot be skipped or condensed into short time intervals without risking failure . . .
Is the above an acknowledgement that CCHIT-certified systems are hard to learn and use?
As such, we recommend that the most important 2011 stretch goal for most physicians and hospitals will that physicians and staff become regular and appropriate users of those core EHR functionalities that are relatively easy to implement and use in EHR systems certified under the 2008 CCHIT criteria.
How did CCHIT get introduced above? The only prior statement in the letter was to use only EHR systems that are considered “safe and effective” by a trusted authority.
RECOMMENDATION 4: Required reporting of quality measures should be deferred until 2013, by which time appropriate data capture and sharing should be widely diffused and deeply infused in physician practices and hospitals that have qualified for payments in 2011.
We see placing the reporting of quality measures in advance of reporting measures of meaningful EHR adoption as akin to putting “the cart before the horse.”
In other words, start using CCHIT-certified systems blindly, without a clear vision of what the goals are.
RECOMMENDATION 5: Defer the requirement to “Use CPOE for all order types including medications” to 2013 or beyond.
Implementing full CPOE is an important but complicated undertaking fraught with potential unintended negative consequences if done too quickly or incorrectly. Even in the hands of our most experienced members working in organizations with EHR systems that are already up and running, successfully implementing robust CPOE functionality is generally a challenging, multi-year undertaking that requires careful planning and execution. As such . . . we recommend that a requirement to use CPOE for all order types be deferred to a later phase because it requires more advanced planning, building, testing, training, experience, data capture, data sharing and decision support than many practices and hospitals can successfully achieve in the next 2-3 years. Ambulatory e-prescribing is a notable CPOE exception that we are comfortable recommending for 2011 because it is a mature enough technology to be reasonably considered “ready for prime time.”
Is this an acknowledgement by AMDIS that new installs of CCHIT-certified hospital EHRs won’t have CPOE reliably working after 2-3 years? Also, as Al noted, AMDIS altruistically seems to feel that CPOE is just fine for the other guy – that is – ambulatory.