Over the past year or so, we have had a lot of questions here at PCC about CCHIT certification. "Will PCC's EHR be certified? Is a non-CCHIT certified EHR bad? Do we need a CCHIT certified EHR?"
What is CCHIT? For those who aren't dealing with every day, it a certification process by which an EMR/EHR is reviewed by a third party (known as CCHIT) for certification that particular features exist in the EHR.
If only it were only that simple...unfortunately, there are many in our business who have ascribed far more to CCHIT certification than it covers. This is particularly deadly for pediatricians (as I'll discuss below). Worse, CCHIT certification doesn't even certify that the EHR has the features it certifies!
Combine this with the growing feeling of a grand conspiracy theory in the making, and we're having fun.
So, just as I got another call about it this morning, I happened to read three consecutive pieces that begin to question a lot of the FUD spread in our industry about CCHIT. I'm in a list making mood, so...here are links to the articles I read:
Required Reading Start
What IS CCHIT?
What IS NOT CCHIT?
Why Does This Matter to Pediatricians?
I make all these comments outside the context of what we plan to do with the EHR. We don't have a choice: we'll be CCHIT certified, just like everyone else, when we complete those features. But it will cost us valuable time and money to jump through a hoop just to get a little logo we can stick on our WWW page. CCHIT certification won't make PCC's EHR any better.
After my original posting about CCHIT and pediatricians, I heard from a number of folks off-line. I had the beginning of an excellent conversation of someone associated with the AAP's effort to promote pediatric-specific features within the CCHIT process, but vacations, snow days, and fire alarms intervened. I hope to get back to that conversation so we can hear the AAP's side of the story.
One interesting piece I received is from softwareadvice.com. I will copy their message to me with my comments in red. Even though they are a service that directs you to a number of our competitors, I think their brief summary of the CCHIT certification pros and cons is good. Read this and the accompanying article. Please note: my comments are not aimed at the messenger, as their review of the facts is quite correct. It just gives me a good chance to get out the soapbox.
As you may already know, the debate on CCHIT certification is intense and physicians are trying to determine what role the certification should play in their EHR selection. We recently wrote a fair and balanced article on
the topic that we wanted to present to you: http://www.softwareadvice.com/articles/medical/should-cchit-influence-your-ehr-selection/
Here are five of the key takeaways from our analysis:
* CCHIT has developed an important set of criteria for functionality, interoperability and security that can help physicians better understand what an EMR can deliver. These criteria could help consolidate the EHR market, which some argue is over-populated with software products.
Unfortunately, even if this were true (they really don't have the interoperability piece down yet, do they?), it still leaves many, many important issues open unresolved and the vendors, in particular, are deliberately clouding the issue. You'll see my comments below.
* CCHIT is binary in nature. While it specifies 250+ qualification criteria, not every physician will need all of those capabilities. So, physicians seeking a low-cost or "lightweight" EHR should understand why the products they like may not be CCHIT certified (i.e. the product did not have every one of the 250+ criteria, even if it had
most of them).
I agree, but I'd like to expand this definition: it's not just the low-cost and "lightweight" EHRs that lack CCHIT certification. Look at Office Practicum in the pediatric market (from a pediatric perspective, perhaps the most heavy-weight of them). Further, the term "lightweight" implies that there are features or services missing from the product that might be important - not so. In particular - and this is where the confusion reigns - many of the "lightweight" vendors have support that runs circles around certified vendors. Still, they make an important point.
* CCHIT may have an impact on the reimbursements physicians receive. Being the only federally recognized certification body for EHRs, CCHIT can improve a physician's ability to participate in payment incentive programs from the Centers for Medicare & Medicaid Services (CMS) and other payers.
May?! PCC clients in any number of locales already face constant pressure to use an EHR - never suited to pediatrics, of course - or face financial consequences. Their list of choices would almost always force them to stop using PCC, which they don't want to do, so they are stuck. Ultimately, the federal push to ram CCHIT down the throats of the physicians acts specifically as a barrier to businesses such as ours.
The irony of this is that PCC has yet to see a P4P program that Partner (our billing system) can't provide the data to in a fashion often better than most EHRs. I specifically did work for an unnamed HMO in an unnamed-New England state, for example, where I went through their P4P measurements (all of which are modeled after the CMS measurements). I pointed out that we could provide the measurements, tomorrow, for any PCC customer in the state without having to change our billing software. Free. No cost. Don't have to change a thing.
"But you're not a CCHIT certified EHR." So even though we have the data, even though it would be free, the HMO isn't interested. Instead, the HMO will force all the providers in the state onto one from a short list of CCHIT certified EHRs...none of which is even remotely suspected to be appropriate for pediatrics. [BTW, I'm not talking about Partners in MA, as their article references - we have plenty of clients dealing with that challenge.]
* An important element of EHR selection is the product's ability to support specialties with unique EHR requirements. CCHIT does not analyze specialty-specific EHR requirements at this time, but intends to start this year, beginning with a focus on cardiology and pediatrics.
I agree, but I can't wait to see what the pediatric criteria are. I know some of the folks who are part of that process (fortunately, they are practicing physicians).
* CCHIT doesn't evaluate all criteria a physician should consider when selecting an EHR. For example, it doesn't evaluate ease-of-use, customer support or the financial viability of the company offering the EHR software. CCHIT makes this clear in their 2007 Physician's Guide.
CCHIT can make this clear all day long, but it doesn't matter. The vendors, in particular, are glossing over this INCREDIBLY IMPORTANT PIECE OF INFORMATION. And, with the MCOs and states making CCHIT the single barrier-of-entry for their approved vendor list, this lack of understanding doesn't even matter. They've hit the nail on the head, here, but not enough people are getting this message.
Thanks to the folks from Software Advice, I appreciate their effort to get this word out. I hope they don't mind my markup too much...
The AMA reports that:
The Massachusetts Blues believes that the return on physicians' investment doesn't warrant buying the technology as part of its bonus programs.
...so BCBS of MA is no longer going to pay for its docs to get an EHR. Meanwhile, Vermont's own VITL project has done an about face regarding the funding of EHRs and has asked that the state provide the funding, "with money raised by a fee or surcharge on medical claims."
Does anyone on this planet actually think this cost simply won't be passed back to the doctors and patients? Does anyone imagine that Aetna/CIGNA/MVP simply won't lower reimbursements by the amount required to offset the $$? This doesn't even pass the laugh test.
Sadly, the $16-30m the proposed tax would raise can only be spent on a list of five pre-chosen vendors, none of whom have a particular understanding of pediatrics. I've spoken about this before.
Ironically, no one locally has remarked on the Allscripts sale to Mysis, which is officially being pegged as a layoff opportunity. Allscripts, you see, has a big office a few miles from here (right within the IDX/GE campus - I've never understood the relationship) and the jobs of hundreds of locals are threatened. It's no surprise that the local media haven't figured this out, yet. I wonder if any of the VT docs who choose Allscripts with the vision of it being a local product realize what's going on?
A proper blogger would take the time to indicate whom he thinks should be paying for EMRs. To be honest, I don't know - we are all going to pay if we don't do it. And nearly all of the payment schemes I see make the patients and docs pay for it, directly or indirectly. I don't like the gov't paying for it (the effect of its intrusion in the form of CCHIT certification has been negative so far, imo). Where does that leave us?
I'll never know. More about SOAPM, merging practices, etc., tomorrow.
I have been critical of the CCHIT certification process before. My position hasn't changed: CCHIT certification is misused and misunderstood by too many people in this business and it is driving up development costs, especially for private practice pediatricians. I don't think this is directly the fault of the organization itself, per se, but it is the practical result. I might have some input on this matter in the future, but for now, I will take a few minutes to examine some of the problems I see with the new child health criteria.
First, needs outside of pediatrics being pushed into our realm. In 2008, EHR vendors will need the following functionality:
The system shall capture patient growth parameters:
including weight, height or length, head circumference;
and vital signs including: blood pressure, temperature,
heart rate, respiratory rate, and severity of pain as
discrete elements of structured data.
That sounds great...until the last item. Severity of pain? Is that really necessary as a requirement for a pediatric office? You can't even begin to measure this subjective vital, as a practical matter, until the children reach a particular age (6? 8?) without using things like the FLACC scale (which, and forgive me if I'm wrong, I've never actually seen in regular use in a private pediatric practice). According to CCHIT itself, this is because of JCAHO requirements.
You'll note that other folks in my shoes have similar questions (look at line 7).
Is it a big deal? No, it's not the end of the world. But now, any EHR vendor who wants to focus on pediatrics is going to be forced to add the "Pain" vital when I don't know a single pediatric office that has asked for it. It will take up important space on the screen, it's another data element to track, and resources are spent on something whose impact on improved or more efficient is minimal, at best.
How about this item:
The system shall synchronize immunization histories with a
public health immunization registry according to applicable
laws and regulations.
Now, note that it says "a" public health immunization registry. So, all PCC would have to do is interface with, say, Vermont's registry, and we'd be certified? Forget that VT serves a handful of pediatricians when compared to NY or TX or CA? Don't get me wrong - CCHIT has its hands tied on this one. The state of immunization registries in this country is an absolute disaster (believe me, PCC interfaces with more of them than anyone). To make this a requirement when there is no standard among them is a mistake. As much as we want to have our registries integrated with EHRs, I think CCHIT should have chosen a standard and pointed to it instead of leaving it helplessly defined.
Finally - for now - I see some big gaps in the understanding of improved pediatric care. Where are the demands for tracking preventive care? Chronic care? Instead of ensuring that the system can indicate that the gender of each patient is unknown (<sarcasm>now THAT feature is long overdue</sarcsasm>), why not have an EHR tell you when a child is overdue for a physical? Or for a recheck? Why not interface with the Bright Futures schedule?
Why will CCHIT require, in 2009, that "The system shall capture the breast milk aliquot identifying data, amount, route, expiration date and date/time of administration" and not have any proper understanding of family mechanics (it only requires custodial information; it has no linking of siblings or families)? Talk about features missing from just about any non-pediatric system now, and we're forcing vendors to track breast milk data?
The letter begins:
The Certification Commission for Healthcare Information Technology (CCHIT) is pleased to notify you that you have been selected to serve as a member of the Child Health Workgroup for our 2008-2009 certification development.
More than once, I have complained about the misuse and misunderstanding of CCHIT certification, especially for pediatricians. And I see, on places like the MGMA mailing lists, a fairly constant stream of dangerous commentary ("You should only consider systems that are CCHIT certified, as that guarantees XYZ." Which it doesn't.).
An intrepid reader of this blog suggested I apply to participate on Child Health Committee. After all, wouldn't it be hypocritical of me to complain about the certification and not do something about it? I applied and suspect that any gaps in my CV related to pediatricians/computers/clinical IT were filled by having a few friends in the right places and here I am. The first meeting is in July.
So...if you have any questions, comments, input, etc., related to electronic health/medical records for children, lay them on me. I sincerely intend to represent the "typical practicing pediatrician" during this process and will use my experience in the hundreds of offices I know and have visited. If you have an experience you'd like to relate or a question you'd like to ask or an issue you'd like addressed, share it here or email me directly. To date, I don't think that CCHIT has done much good for pediatricians - in fact, I think it has done some harm. And the path that they are on seems somewhat beholden to other interests (why Child Health certified EMR vendors will be required to track "Pain Levels" before growth charts is a good example). But my perspective on that isn't nearly as powerful as yours.
Cross your fingers and wish me luck! [Oh, John Canning made it on a workgroup or two himself - TWO PCCers with their toes in the door of CCHIT! They don't know what they're in for.]
I am in lovely Chicago prepping for my CCHIT Child Health Group meeting over the next two days. Most of my prep has been practicing saying C-C-H-I-T instead of "C-CHIT". Apparently, the latter is gauche.
On the list of 12 other members of our workgroup, I believe I know three folks already. Nearly all of the others are MDs and all but one or two work for BIG organizations. Given that I lack the aforementioned MD - or MBA, MPH, PhD, MSHI, or PharmD - that my co-members have, we'll see how much I stick out tomorrow. I don't believe that the events are private and I do intend to take notes, so whatever I can share, I will share. Whatever I can't, I won't. I have heard from a few folks (our EHR using clients) who have some input, I'll let you know what happens!
In the midst of our CCHIT Guidance morning, we've been getting a bit of a lecture about how to communicate issues relating to CCHIT. Who speaks for whom, what information we can share, etc. There was, in fact, a slide specifically telling us to call it C-C-H-I-T and not C-CHIT (as I've only heard it called until here), an event that approached satire. Then, to my surprise (and their credit), Rick Turoczy mentioned the "bloggers out there" and mentioned that we have to be careful not to misstate the fact that we don't speak for C-C-H-I-T (which I hope I haven't done) or share non-public information. And then he called me out by name. Yikes.
I don't think he knows what I look like, so I can hide from him for a little bit.
One thing I find funny is that during the orientation kick-off yesterday (with about 50 people) and today with the entire group (with 200), about 1/2 or more of the questions are asked by people from the Child Health workgroup. Yesterday, John, Dr. Kressly, Dr. Yu, and I were easily the pushiest folks. Yes, we are pains in the butt.
So, my opinions related to the EHR certification process are my opinions only. I certainly don't speak for CCHIT!
Rick, stop by here and say hello.
I may have some more, legit comments about this process so far later, but I also have a stack of other data for folks to come, too. And I have to prepare for our UC.
[As for how to pronounce the name of this org, I think they are swimming upstream. All the brand identity work in the world can't undue every doc and OM calling it C-CHIT. I'll do my best, though.]
Update: I introduced myself to Rick and I we had a nice chat. I think my future critiques of C C H I T (presuming I have some, of course) will be welcomed.
With the Obama administration arrival only a few weeks away, the discussion about CCHIT’s long-term viability is starting to heat up. Even though I am on the Child Health Workgroup and appreciate the effort and intelligence of the civilians working with me, I still have grave concerns about the process and it’s effect on EHR development. I’m sure it has benefited any number of physicians, but in the sphere that I work in (private pediatric offices), all it has really done is increase costs and eliminate vendors.
I’m not alone in my thinking. Some of the folks over at emrupdate.com (namely, Dr. Al Borges) have been quite vocal about it. You can see his comment here on histalk2.com, which led me to a damning article on ZDNet and other links.
As you may know, I am on the CCHIT Child Health Workgroup. My participation is related, I believe, to my criticism of the certification and it’s misuse. But if you’re not part of the solution, you’re part of the problem, so there I am on the workgroup itself. I think I am the only committee member who hasn’t missed a meeting, so I can at least say that I’ve shown up and put in my $.02.
For the last six months or so, my esteemed colleagues and I have fought - though nicely - over line-item after line-item in the new criteria for CCHIT Child Health certification. Are we forcing vendors to do too much? Is this a feature that a small, private-office pediatrician needs or want? Sure, we all know how important growth charts are…but where can we get “official” data? How about tricky items like dosing and age calculation?
Without editorializing, our group poured a lot of effort into these questions and I, at least, was a bit surprised at the results. The combined knowledge of life in an ambulatory pediatric office within our group is profound, yet the commissioners (some of whose expertise I question) felt we didn’t get it right and amended some of our requirements at the last minute. The process itself is definitely bad, in this instance, but I can’t say that the results are. Yet.
But don’t take my word for it. Time for the public commentary is now, so head here or, specifically for Child Health, here. There are instructions at the bottom of the page for your feedback and I know, from personal experience, that your feedback has a profound impact. Without directing you to one position or another, I would specifically love to know from practicing pediatricians (with or without EHRs) whether tracking a patient’s age in hours or even minutes is ever important? How about body-surface dosing? These are the issues we debated (at every meeting, literally) and I am fascinated to get some feedback. And it’s your chance to help direct the pediatric focus within EHRs. If you don’t add your $.02, it’s harder to complain later.
Edit: Just received this timely link via PedTalk. A great read. Short on the budget, but it hits the mark for me with most of the comments.
These things always happen when I can least afford to spend time working on them. When I leave town, for example, and can't get my mail...PedTalk usually explodes. This time, it's school break and we received the following at PCC:
Re: Offensive blog postings regarding HIMSS and CCHIT
Dear Mr. Hart & Mr. Canning:
Our law firm represents Healthcare Information Management and Systems Society (“HIMMS”) [sic]. It has recently come to our attention an individual using a pseudonym has been posting offensive and potentially defamatory material about HIMSS on Chip Hart’s website “Confessions of a Pediatric Practice Consultant.” The post was made in response to the December 7, 2008 article “CCHIT and OSS.” The offensive and potentially defamatory material was posted was by “Rocky Ostrand” at 1:59 a.m. on January 30, 2009 and can be found at this web address: http://chipsblog.pcc.com/?p=279
We are requesting your assistance with the following:
(1) Please remove the offensive post from your website.
(2) Please provide us with “Rocky Ostrand’s” e-mail address, IP address, and any other information you may have that would help us identify his or her true identity.
(3) Because we may take legal appropriate legal action against “Rocky Ostrand,” please preserve all records related to the identity of this individual as well as all postings placed by him or her on your website.
Because of the sensitive nature of the posting, we would greatly appreciate it if you could provide us with “Rocky Ostrand’s” e-mail address, IP address, and any other identifying information by February 23rd. Please do not hesitate to contact me if you have any questions.
Very truly yours,
Ernst H. Ostrand
Attorney at Law
Jackson Lewis LLP
320 West Ohio Street, Suite 500
Chicago, Illinois 60654
I admit, I'm scratching my head. Why is a lawyer writing to me? There is no legal issue. No subpeona. No assertion of libel or slander. They're asking me to remove someone's point-of-view because they find it "offensive" and, worse, asking me to identify the poster (which, technically, I can't). They would appreciate me doing all this by today, as though PCC has free resources to toss around answering to their requests. And then I have to save it all so they can persue some legal action. At least it's polite!
There's only one reason for a lawyer to send us a letter like this. To intimidate. It's a "cyber SLAPP" and more than 1/2 the states have laws against this behavior, though Vermont is not among them. I suppose having a lawyer ask me to remove the material is easier than responding to it most of the time. We're not going to remove it, though. We're going to do the opposite.
Don't get me wrong - PCC is a very small company. We're in business to help our clients improve the health care of children. I'd rather spend our limited resources on something important, like keeping kids from dying from the flu, rather than help our largest competitors lick their wounded egos.
The thing is...it's 2009! Don't these folks realize that asking us to remove the content is ridiculous? Google has already cached it. It's already in the wild. HIMSS has two choices: ignore it or respond to it. Frankly. I'd suggest the latter.
Don't mistake my position. I don't support the comments that were left on my blog. They are somewhat ridiculous - the two Leavitts are secretly related and conspiring and we're not supposed to realize that? C'mon! But if HIMSS and CCHIT have nothing to hide, why are attorneys sending letters? The right thing to do is kill 'em with facts.
I'll even run a response verbatim, give HIMSS full exposure. I know that CCHIT has done this elsewhere (they've got smarter lawyers and/or PR, apparently). I invite HIMSS to respond here...the mic is open.