Dear Mr. Lowes:
I would like to provide feedback on your Medical Economics article- "The Best Ehrs For Small Practices - A Comprehensive Survey From Two Companies Reveal The Cream Of The Crop." which I read at http://www.memag.com/memag/article/articleDetail.jsp?id=367341&pageID=1&sk=&date=.
This was an excellent article! You did a very good job at highlighting the process of selecting an EMR for the typical physician purchaser. I am an oncologist in private practice in Virginia who has had a keen interest in electronic medical records (EMRs). I have been programming EMR systems since 1990. One such software that has been downloaded over 2000 times since it was made available for free download was my MS Word EMR Project, v4 (the download can be found at http://briefcase.yahoo.com/alborgmd ).
A large group of us discuss EMRs on a daily basis at http://www.emrupdate.com . I would like to present to you some information based on our discussions at this site, especially concerning the CCHIT process that you will be going into further later on in an October issue of Medical Economics. CCHIT has been very successful at obtaining support from both government and from several medical societies, so most reviewers unfortunately take what they say at face value. Many facts that are posted are poorly understood and/or outright wrong. I would like to take a moment with this email to clarify some facts:
1) You state: "CCHIT certification, which we'll examine in-depth in a supplement to our Oct. 6 issue, is a critical tool for EHR buyers, but it doesn't speak to how fast a vendor will fix a bug in its program. Or if it has a reputation for fairness. Nor will it help you determine how responsive a vendor's help desk is if the system crashes—an important factor for a small group practice that doesn't have an in-house IT expert."
You are correct on everything here. You might wish to add that they still do not address the most important feature that EMRs should have- INTEROPERABILITY. They don't plan to fully address interoperability for another 3 years.
2) You state: "Selecting an EHR solely on technical merits became immensely easier in July when a private, not-for-profit group called the Certification Commission for Healthcare Information Technology announced the first programs to receive its stamp of approval."
CCHIT is an LLC corporation comprised by "vendor stakeholder groups" among "other stakeholder groups". If you go to http://www.cchit.org/NR/rdonlyres/527C461A-2471-4D8A-88BC-8BE45A14D7A0/0/CCHITOperatingAgreement_asof_20060119_Finalsigned.pdf , it'll mention how all profits and losses will be distributed amongst it's "members".
You can still skim off the top a lot of money from a not-for-profit corporate entity. Why do you think they want to charge so much for the year-to-year certification? They hope to make a heck of a profit on this certification process. The $616,000.00 made by testing the initial 22 EMRs is much more than is needed to be "self sustaining". They will be doing this testing on a quarterly basis, so this will mean that they will skim off much needed vendor profits at a tune of over $2.4 million dollars a year. This is money that will eventually be passed on to physicians increasing their already high cost of ownership. Other URLs: http://www.cchit.org/about/policies.htm, http://www.emrupdate.com/forums/thread/51472.aspx , and http://www.emrupdate.com/forums/thread/51469.aspx .
3) CCHIT states: "Improved Sales: CCHIT’s certification program is intended to accelerate EHR adoption and to increase the confidence that physicians and other providers have in making a purchasing decision.". (http://www.cchit.org/vendors/learn/ )
Although CCHIT will definitely lead to "improved sales" for certified EMRs, overall it will decrease competition by making this costly process out of reach to small competitive startup EMR companies that offer targeted EMRs for low cost and even for free. This decreased competition will cause a consolidation in the marketplace leading to overall increased prices for EMRs. Adding on an expensive certification process that may entail as much as $28,000.00 a year cost will be passed on to the end user also in the form of increased prices. The already high priced EMRs becoming costlier will lead to decreased EMR purchases by physicians. This is discussed further in my recent newsletter which can be downloaded at http://www.emrupdate.com/blogs/news/default.aspx . Two interesting facts found in this newsletter include:
· One study performed by Fritz Switzer who took the "EMR Price Matrix" located at http://www.emrupdate.com/resources/pricecomparisons.aspx and compared the prices of CCHIT EMRs vs. Non-CCHIT EMRS. Here is what he found-
o Average EMR/Product cost (all companies) = $18,776.50
o Average EMR/Product cost (CCHIT Certified) = $30,690.80
o Average EMR/Product cost (non-Certified) = $17,066.00
· Nearly one in four (23.9 percent) of physicians reported using full or partial electronic medical records (EMRs) in their office-based practice in 2005 - a 31 percent increase from the 18.2 percent reported in 2001. CCHIT advocates claim that for the 2006-2007 year certification of EMRs will bring about a 30 percent increase from the current 24% level. I personally will be interested if their predictions come true. URLs: http://www.cdc.gov/od/oc/Media/pressrel/a060721.htm and http://www.genengnews.com/news/bnitem.aspx?name=4557625 .
You might be interested in a lecture that I gave to the Washington Hospital Center in December of 2005. The URL for this slide show download is http://www.emrupdate.com/files/default.aspx . In that slide show I further discuss the problems with CCHIT such as the massive actual programming costs that it takes to implement the CCHIT criteria. In this lecture I discuss EMR rating presentations, from Klas and the AC Group that you go into so well in your article to the recent aafp survey of 408 physicians and of course, TERP.
Other references that you may wish to review are the 2 quarterly newsletters from emrupdate.com that can be found at:
· http://www.emrupdate.com/blogs/news/archive/2006/05/03/49643.aspx
· http://www.emrupdate.com/blogs/news/default.aspx
I also wrote a letter to CCHIT’s Dr. Mark Leavitt (see http://www.emrupdate.com/forums/permalink/46564/46564/ShowThread.aspx#46564 ).
You will see that my intention in all of this is to see a large level playing field for EMR vendors leading to higher market competition and eventually to lower cost or free EMRs to all physicians. If I or any of our other discussion leaders at http://www.emrupdate.com can be of help in your follow-up article, please do not hesitate to write or to call us. Thank you for your kind attention to this subject matter.
Sincerely,
Dr. Borges
Alberto A. Borges, MD (alborgmd@yahoo.com )
Al Borges, M.D.
● Oncologist in a Small Group Practice in Virginia
● My website URL: http://msofficeemrproject.com/
The one thing that I regret about the letter is that it obviously is down on CCHIT but offers little in the area of alternatives. Instead of the CCHIT we know of today, we should:
Cheers,
Al
Graham http://www.synapsedirect.com/ Synapse - the EMR for smart users
Their financial disclosure contract highlighted in the letter clearly states "YES".
I wonder what Dr. David Winn can say about this. His eMDs company is one of the 20 that formed the initial "investor group" involved in the process. I feel that government is clearly skirting its responsibility on this one.
I am hoping that Medical Economics can highlight these CCHIT controversies for all to see, not just us EMR techies.
>>> Is there a monopolies commision in the USA?
There are "antitrust" laws, but when they have the backing of the executive branch of government, they can do as they wish. There are 2 forces which can deter this abuse from CCHIT:
Interestingly, other countries want to increase the prevalence of IT/EMR, but mostly through government initiatives targeted at specific criteria and interoperability. They are shouldering the cost of EMR acquisition. There is more on this here.
Per Michael Leavitt, Health and Human Services Secretary:
This seal of certification removes a significant barrier to widespread adoption of electronic health records. It gives health care providers peace of mind to know they are purchasing a product that is functional and interoperable, and will bring higher quality and safer care to patients.
These sorts-of-things bore me and I don't usually visit this thread, but this is becoming interesting. It is my understanding that CCHIT is industry sponsored and is designed to, "level the playing field."
Observations:
Great letter, BTW, Al.
Great letter, Al. BTW Robert Lowes, while a senior editor at Medical Economics, is not a physician (nor a Ph.D). He has written much in the past to promote EMR use amount curious physicians.
Andy Schuman, M.D. ,
Developer, Practical Medical Record
alborg: Their financial disclosure contract highlighted in the letter clearly states "YES". I wonder what Dr. David Winn can say about this. His eMDs company is one of the 20 that formed the initial "investor group" involved in the process. I feel that government is clearly skirting its responsibility on this one.
Do any vendors profit from CCHIT? Well, I have spoken to this, at least indirectly, on several threads. The theory goes that a CCHIT certified vendor will win a sale over an otherwise equal, but nonCCHIT certified vendor. I think that statement is probably accurate - if all other things are equal.... but, in answer to Al's anticipated rebuttal, "if they are otherwise equal why aren't both vendors CCHIT certified?" A: One will pay $28,000 annually, the other will not.
CCHIT is clearly dominated by the big vendors. These vendors have their own government affairs representatives who aggressively lobby for their agenda. emrupdate could be a force for good and organize it's own 'lobbyist', if only to go to the CCHIT public forums and post questions/concerns about proposed future certification criteria. Public comments are taken seriously and can be a huge impetus for change. The EHRVA actively seeks to 'water down' CCHIT criteria, but, alas, the EHRVA is still slave to it's big brother vendors and therefore, speaks in IHE/HL7. Anyone who reads my opinion on this matter is that CCHIT should be a 'minimalist' org that only defines a critical, but small subset of EHR functionality. Unfortunately each CCHIT constituent has their own agenda, so the certification criteria continue to grow and grow. Instead of allowing the free market to pick innovative products and determine the winners and losers, we are allowing a "designed by committee" org to dictate what our products will do. We have actually had to program administrator overrides to CCHIT functionality in those cases where a security requirement for a small office is so over the top that it would impede usability.
I believe with CCHIT we will see interoperability drawn out over 5-7 years along the IHE/HL7 path in order to protect the biggest vendor's proprietary systems. I suspect compliance with the IHE platform will be one of the requirements to future CCHIT certification. In the meantime CCR will chug along unnoticed by the GEs of the world, but will be providing a high level of interoperability among the "little people". Forces for change frequently come from unexpected places. I think CCR, Alborg, open source, emrupdate and various other forces will continue to shape the industry for the better despite the obstacles thrown at us by the government and big business.
Just to make sure I answered your question Al... the management team at e-MDs believes that CCHIT certification is a necessary evil. With it, we get the blessings of the experts and consultants, many of whom I have bashed over the years (I would hate for Anderson to be able to say "I told you so") With it we participate in the big RFPs and win the big deals. Without it, we are simply scratched off the list before we even get a chance to strut our stuff. It's an unpleasant reality, but a reality nonetheless. Other than higher sales to the detriment of our nonCCHIT certified competitors, there is no financial gain or relationship for us.
Disclaimer: I am the founder of e-MDs. Highest rated by doctors. All posts are opinion only
But David:
Who makes up the "investor group" that is profiting from the money that CCHIT-certified EMRs have had to pony up? Do you know how much they make out of the over-$600000.00 per certification session that is paid?
Thanks,
For each certification session there is a panel of three anonymous, but supposedly highly qualified judges and a moderator. They are paid generously for their time to sit in and verify the vendor functionality. I would say if anyone here wants to apply to be a judge, it probably pays much better than seeing patients. As for the rest, they pay a CCHIT czar/CEO. No way does it cost $28,000 to certify a product. CCHIT profit margins must be very high indeed as the work groups are all unpaid volunteers. We had 100 Tshirts made after we certified that say "We went thru CCHIT to get certified". They cost us over $2200 each. That is the estimated added development cost of $200,000 plus $28,000 plus $7 per shirt.
Is this CCHIT worth 200 grand per year? (200k because that is the cost of diverted development resources to assure you meet cert criteria) No, it is not. Who pays for it? I think mainly the nonCCHIT certified vendors. We can't really raise our prices - they are set by free market forces. If anything there is downward pressure on pricing. What CCHIT does for us, eCW and other CCHIT certified products is allow us to win more deals against nonCCHIT certified products. We win or break even while the other vendor's continue to bleed. At least that is what I think is happening. It may be that everything goes Open Source and nobody makes any money - but frankly I doubt that will happen. EHRs are too much of a niche market and require too many 'expensive' HL7 interfaces to ever be free.
I am curious also. What happens when a government sanctioned body has a guaranteed annuity that is growing at a logarithmic rate? I predict it will need to find a reason to spend that money and that will come in the form of greater restrictions and requirements on EHR vendors. It may be that they so stifle innovation and add so much cost to the process that only hospital vendors will be able to afford development and docs using EHRs will become tied to the local hospital supplying them with their technology. I actually believe that is exactly what Cerner is trying to do by lobbying for relaxation of Starke laws. Is this all just a huge conspiracy to put doctors under the control of hospitals and the government? Nah, sounds too Orwellian or as I like to say, just because you're paranoid doesn't mean people aren't out to get you!