pediatric emr

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.]

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.