Posts tagged with ehr

I was on the phone yesterday with a client from Rhode Island who was taking the time to tell me about his practice's search for an EHR. To my surprise, they had flown down to visit another customer of ours in Tennessee to see what they thought of an installation with one of our EHR partners. They gave him some interesting advice: take your time. Even though the TN practice is happy and up-and-running with the EHR, they realized that it has taken them a year or more to figure out what, exactly, they want and expect from it. And that has cost them time and money. [Note: the EHR company in question has served them well; this is a classic practice management issue.]

Which makes me feel that I know what I'm talking about sometimes.

You see, a few weeks ago, I was honored to give a presentation at the VT AAP fall meeting. My discussion was entitled "Choosing a Pediatric Electronic Health Record". Perhaps it was "Preparing for..." In fact, I think I can use Wordpress to post the presentation. In any event, the fundamental point from the entire presentation is:

The single biggest and most common mistake practices make when choosing an EHR is to learn what they need after they purchase the system.

Look at that!

Now, many of you read this blog have heard me speak, but there are plenty of you who haven't. Although common sense and not false modesty tells me that I'm far from the world's greatest speaker, I think I'm often better in person than I am in writing. My brain seems to enjoy the challenge of making things up on-the-fly, which means I sometimes end up saying things in a presentation that I would have never thought to communicate in writing. So, there, in the middle of my talk, I blurted out:

Purchasing an EHR before organizing your practice and knowing exactly what to expect is like having kids to save a marriage. Sometimes it works, but it usually doesn't. And it's always more expensive.

Now, maybe that doesn't ring as true in the middle of a blog as it did 45 minutes into a lecture about the subject, but I saw the lightbulbs turn on in the eyes all around the room, so I thought I'd record that analogy before I forget it. And extend it poorly with some comment about birth control.

So, if you're shopping for an EHR - take your time and prepare. Want some suggestions? Just ask.

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

• One of the better-informed pieces about the CCHIT dilemma from our friends at Physician's Practice magazine. Although some of the quotes are scary, I was impressed with the depth of view that PP took here. Required reading.
• Over at emrupdate.com, you'll see the discussion surrounding the FTC-level complaints that folks there have submitted. They see a problem with the largest EHR vendors effectively owning and controlling these certifications. I do, too, and anyone who thinks otherwise hasn't spent enough time in the medical software industry. There's plenty more reading at emrupdate.
• Here's an interesting blog entry from "EMR and HIPAA" which raises many of the same concerns.

What IS CCHIT?

• It is a collection of large, self-interested private organizations charging an exclusionary level of money for a certification that doesn't ensure that the EHR in question won't rip you off. Who runs CCHIT, the organization that certifies EHRs? Why, it's the presidents of some of the biggest EHRs and insurance companies in the country! Don't get me wrong: I'd be concerned if some of these folks weren't there.
• Cynicism aside, it is simply a tool that tells you whether the software had, at one time, the features required in CCHIT certification. Unfortunately, that means a vendor may have been certified in 2005 and not made any changes or improvements in 2008 and still maintain its certification.
• Ultimately, it's a tool backed by the Fed to put into a place the ability of Medicare (and the privates to follow) a way to pay those without EHR less. This isn't conjecture.

What IS NOT CCHIT?

• It's not a guarantee that the company in question will stay in business. Or that the software is easy to use. Or that it will interface with anyone else. Or that it won't triple its pricing next week. Or that it will be owned and run by the people who sold it to you. Or that the features are actually still working or are maintained.
• It's not a guarantee that the company in question knows anything about pediatrics or has any pediatric features. How many CCHIT certified vendors interface with immunization registries, for example? Or can crank out a list of kids who need flu shots based on the latest AAP/CDC criteria? If it does...that's not because it's a CCHIT requirement.
• It is not any kind of guarantee that the EHR comes with good support!

Why Does This Matter to Pediatricians?

• First and foremost, it's killing the very people who might help you. Has anyone here noticed that pediatricians are at the bottom of the reimbursement totem pole? And that many of the companies who support you are not the multi-billion dollar businesses for whom the $250K investment for certification is viable? Some of the best pediatric EHRs out there aren't CCHIT certified. Look at Office Practicum, for example (who competes directly with PCC all the time, btw). Good EHR. Can knock the socks off just about all the certified vendors for a pediatric office. But isn't certified, last I knew. If you think the great pediatric EHR is going to come from a company that works with hospitals as a rule...well, look at how well that worked in the PM side of things.
• Because of the non-pediatric perspective of CCHIT, it means that vendors will have to commit resources to developing features in their systems in order to get certification that may never even be used! You can already read about this over on emrupdate.com. We partner with some of these vendors and have reviewed the systems of just about all of them - some of their adherence to the features is ridiculous at best!
• Funding. Many of you come to us to say that your local hospital/HMO/state/county will give you money for an EHR...as long as its CCHIT certified. A good example is right here in Vermont, where VITL has provided a "Pre-Screened EHR Product List." Pick from this list of vendors and you get a coupon! However, check out the list: for every pediatric office who likes and uses NextGen, I can find you ten who can't afford it and five who use it and don't like it. So...VITL eliminates a superior product like Office Practicum or Chartcare from consideration by Vermont pediatricians simply because some larger organizations proved to themselves that they had features that aren't even appropriate for pediatrics.
• The AAP itself is headed this way. We have been told, straight up: to participate in the pediatric vendor showdown, you have to be CCHIT certified.

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...

Back in March, I reacted to a piece from softwareadvice.com about CCHIT certification and even though I ripped through it honestly, I think they were appreciative of the coverage and sent me a reference to a new piece:

5 Ways Physicians Can Profit from Using an EMR.

I'm on vacation this week, so I don't have the time to go through it like I did the other piece, but I think it does a decent job of touching on most of the big ROI features of an EHR. However, I think it's missing a few much more important items:

• Time saved by the physician. Many of our clients, once they get good at using their EHRs, find themselves leaving on time at the end of the day or not having to track down charts themselves. What's that worth?
• Remote access! It's 3am and you get that emergency call. Electronic access to your records can be priceless.
• Most importantly: the opportunity to provide much better care. Whether it's medication checks, clinical warnings, legible notes, etc., etc., the primary benefit of your EHR had better go to your patients - and reap the benefits of that!

Still, I wouldn't toss up this reference if it weren't a helpful, quick read, especially knowing that softwareadvice.com supports many of our competitors!

In a week or two, I am going to rip through their piece about ASPs!

CCHIT has announced the new optional Child Health Certification Criteria. Click on the link, read the PDF, get a sense of what hoops the pediatric EHR world is going to have to jump through shortly.

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?

I'm not the only one so have this frustration with CCHIT. Check out the SEEDIE certification and Extormity. I admit that I laughed out loud. [Thanks to HISTalk for those.]

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.

I've had a lot of surprisingly hopeful emails hit me referring to all the "free money" docs expect to get as a result of the Obama stimulus package.  Put your cynical hats on, folks, because if you think that the HIT-driven stimulus money as it's designed right now is going to benefit you or your patients, you are mistaken.

First, let's look at the macro-economic issue.  I, and others in this business, feel like the stimulus money will ultimately prop up old-style vendor solutions, none of whom are obviously serving the community well.  Further, tying the $$ to a non-market-driven certification process (c'mon, anyone think it isn't going to be CCHIT?) is going to further drive away the innovation and specialization so needed in this business. This looks exactly like the way we treated Detroit for many years and look what that has gotten us.

Second, let's look at the micro-economic effect.  I can't believe people don't see the problem here.  What do you think is going to happen to the real costs for a new EHR if the vendors think that you're good for an extra $40-70K/doc over the next 5 years?  Do you actually think that physicians are anything more than a conduit through which the money will go from the tax payers to the EHR vendors?  How much of this stimulus $$ do you think will really be found in your margin?  $5000?  $10000 over 5 years?  Is that really even worth talking about, if it leads you to choose the wrong EHR?  

That's crazy.  But it's already happening.

Finally, as pediatricians, you have to take specific care.  Here's something John Canning put together informally for our clients.  Take heed. If you're not 20% Medicaid, you're not getting any $$, it looks like.

Greetings -

Like Chip, I serve on a CCHIT Work Group. My group deals with
Privacy (HIPAA) and Compliance. Our meeting today eventually turned to
the Stimulus package and how it will support IT spending for healthcare
(i.e., EHRs).

We received a copy of a very informative presentation after our
lengthy discussion. It does a great job of summarizing the Medicare and
Medicaid incentives for both physicians and hospitals. I learned some
interesting things about the Medicaid money and pediatricians:

1. In order to qualify for funding, at least 20% of the patient
volume at a practice must be from patients receiving medical assistance
(it doesn't say if we are measuring volume based on visits, people, or
dollars);

2. Each state gets to decide whether or not they will pass on this stimulus money to their Medicaid providers;

3. Each state gets to decide what is required for certification (you must have a certified EHR in order to receive money);

4. There is no indication when the money will first become available, although folks are assuming it will be in 2011;

5. Interestingly, pediatricians only qualify for 2/3 of the federal funding described in the stimulus bill (2/3 of $65,000);

6. I am not clear on how practices that are already using an EHR
would fair under this plan. Some of the wording implies they must begin
using a system in 2010.

All of what I am reporting is based on what is written in to the
bill that was signed by Obama. It's still up to the Department of
Health and Human Services to decide how they are going to actually
implement this. Let's hope they move faster with this program than they
did with HIPAA (it was signed in 1996; the law mandated it go into
effect in 1998, but it didn't really go into effect until 2003).

Cheers!

John 

I don't like to think about the blog on weekends - hey, we're busy preparing for Nowruz! - but I saw this post from Dr. Russell Libby and had to share it.  I wish I had thought to do a similar calculation, but the credit goes to him:

No question about the "new" math.  If a practice has no Medicaid
patients because the state pays at 30% less than their ins reimbursed
rates and they decide to go after the stimulus $ what happens?  If we
gross $5Mil/yr in a 10 FTE practice and could find enough Medicaid
patients in our neighborhood to reach 20% of our revenues (it would
be impossible to identify them as 20% of our patient population) that
would be, assuming 2500pts and 5000 visits/FTEMD/yr, that would be 
5000  new Medicaid patients and  10,000 visits for the group to have
all of the docs qualify for the EMR money.  (I would consider it a
true banner year if I could find so many new patients and get them in
at such a frequency.)  Assuming that the average  revenue/pt visit is
$110  (taken from the most recent surveys in the AAP database), a 30%
hit on that average ticket would be $330K and that would be on a
yearly basis, so that over the 5 years you got the, let's be
unrealistic and optimistic, $70K/MD or $700K  to the practice, it
would cost $1.65 mil in lost revenue.  I know, too many assumptions,
but the reality is that no matter how you dice it, for those of us
who can't afford to have a large Medicaid patient population, the
stimulus money is not really anywhere near the table.

The OCD part of me wishes to point out a few things:

• I don't think the pediatric average revenue/visit is $110;
• I think the average visits/FTEMD should be higher;
• I think most pediatric practices have some Medicaid already, so their need to increase to get >20% is non-existent or smaller;

BUT IT DOESN'T MATTER. His premise is still completely correct, the nitpicks above actually negate each other (I'm sure he knew that and was trying to keep it simple), and I applaud him for pointing out the issue.  Good work.

About a year ago, I shared a piece from softwareadvice.com about CCHIT (on whose Child Health Certification committee I serve).  I found their original response pretty well balanced, so I now pass along their followup to the piece.  I won't go through it like I did last time, as my points haven't changed much, but it's a decent review of the pros and I cons of the CCHIT impact.

I also wanted to point out that another expert has weighed in on the consequences of the Obama HIT stimulus and feels quite similar to how I feel.  Read Jeff Daigrepont's blog entry here (their other blog pieces are good reading, too).