A budding effort to evaluate and certify ambulatory clinical information systems will take aim at the reluctance of payers to subsidize the adoption of electronic medical records by physician practices.
The Certification Commission for Healthcare Information Technology, launched late last month, will be a crucial element of the healthcare industry's drive to "unlock incentives" that are close to being released into the marketplace but are still hung up by uncertainty over how payers can assess the worth of what they would be subsidizing, says Mark Leavitt, director of ambulatory care for the Healthcare Information and Management Systems Society.
"Those prepared to pay incentives have got to have something solidly to say, `You can have an incentive and you can't,' " says Leavitt, a physician and clinical IT pioneer who also serves as medical director of the Chicago-based association for healthcare IT professionals.
Two other healthcare-minded trade groups, the National Alliance for Health Information Technology and the American Health Information Management Association, joined with HIMSS to create the commission in response to strong recommendations for such a private-sector initiative from David Brailer, HHS' national coordinator for health IT adoption (July 12, p. 8).
Both the federal government and private payers have launched initiatives to stem rising healthcare costs by offering extra pay for measurable improvement in the quality of care for certain acute and chronic conditions. But physicians first have to be able to manage the care of all patients with similar ailments, which payers are coming to recognize won't be possible without IT systems to help physicians track certain patient populations and then document the improved care that qualifies for payments.
The new commission's challenge will be to provide enough information about IT products to spur action from physicians and payers without showing favoritism or interfering with the healthcare IT marketplace.
"We don't want to do anything that will stifle innovation or get in the way of market forces," says Linda Kloss, AHIMA's executive vice president and chief executive officer. The move to certify IT products for compliance with a baseline set of features and functions is "an opportunity to compare and contrast products to that standard-certainly not to one another," she says. "It's not a consumer report," Kloss says of the typical anticipated certification assessment. "It's not going to compare how well the system is working and how people feel about it."
Goals for 2005
The certification commission plans to conduct its first meeting Sept. 14, and by late spring or summer of 2005 it plans to have a "beta version" of functions considered the minimum set that must be offered for a vendor to call its product an electronic health record for physician practices, says Leavitt, who will chair the group during its startup phase.
The 13 voting members, he says, will represent three main constituencies: healthcare providers that want to buy IT systems, IT vendors developing the products and looking for direction from the industry, and payers and purchasers who have declared that they are prepared to offer incentives for IT adoption. In addition, the commission will include representation from standards organizations and experts on healthcare informatics. Several nonvoting representatives from the federal government also will be chosen, he says.
As of last week, nominations for all commission members had been privately extended but not all had responded. Leavitt says the panel's charter membership will be announced when acceptance is confirmed by all 13.
Though only about 10% of physicians use any type of clinical IT in their practices, 260 healthcare technology vendors say they sell an electronic medical-records system, says Mark Anderson, principal of the AC Group, a Montgomery, Texas-based firm that evaluates and rates ambulatory IT products.
The lion's share of those systems provide basic record-keeping and charting automation to the clinical side of a physician practice: tracking patient data such as vital signs, current medications, allergies and past procedures as well as improving workflow for nurses and clerical employees, Anderson says.
True electronic medical records go further, providing knowledge about the condition of a patient and guiding clinicians on what to do about a problem presented during an office visit, he says. They contain ample knowledge about a patient's characteristics, and they couple that information with interactive databases-such as drug repositories that inject data about drugs and their possible role in treating given diseases. Among their features, upper-level systems would allow physicians to receive lab reports electronically from outside sources, with abnormal results flagged and suggestions made about likely diagnoses along with recommendations for a course of action, Anderson says.
The inclusion of "clinical couplers"-which tie diagnostic databases to clinical systems to make sense of captured information-separates the basic level of clinical IT from the more advanced systems that address such priorities as assessing the health of patients and keeping them healthy.
But those couplers are the elements most often missing from ambulatory electronic records on the market, Anderson says. As a result, only about a dozen IT companies are marketing products close to meeting his firm's definition of a fully capable electronic medical record. With so many small companies marketing products of limited depth, the certification effort can be instrumental in setting a bar and making them comply, Leavitt says. The exercise not only will isolate subpar products but also "help the marketplace move forward more quickly," he says.
By assembling a base of "conformity criteria," the commission can narrow the field for physicians who don't have any experience in product selection, can't rely on guidance from healthcare IT professionals and "have a minute and a half to think about all of this" in between patient-care and business issues facing their practices, Kloss says. "We help the buyers at least in that first cut," she says.
Lessons from California
The approach has a precedent in California, where an initiative was launched five years ago in Santa Barbara County to harness the economies and flexibility of using Web browsers to send and receive information among hospitals, physician practices, government payers, ancillary services and prominent employers. The collaborative network, called the Santa Barbara County Care Data Exchange, was among several regional projects recently held up as examples of what the federal government sees as building blocks of a nationwide IT strategy.
A certification program for participating vendors in the Santa Barbara project took shape in 2000 under the direction of the initiative's managing firm, Care Science, which at the time was headed by Brailer. To separate product claims from true capabilities, the project identified requirements for building the countywide data-exchange network and then structured a line of questioning that forced vendors to disclose the fitness of their products for aspects of the network (April 10, 2000, p. 102).
The first call for vendor participation attracted 110 responses, and 85 products eventually were submitted for evaluation. The first round of investigation certified 65 products; the remaining 20 were rejected but given time to develop their products more fully and qualify at a later date.
The new national certification effort will consider first the value of required elements to the better functioning of physician practices, Leavitt says. Speaking for himself and not officially for the commission, he says the first line of requirements probably will center on the essentials, such as medication management lists, allergy tracking and patient problem lists.
Because market penetration for IT is so low in outpatient settings and physician offices, the healthcare industry has an opportunity to make products compatible at the outset by organizing standards adoption and priority elements before the product sector can become as fragmented as the hospital IT market was allowed to become, Leavitt says. The effort will have to wade into many issues of functional categories, standards timelines and value for the payer dollar.
The commission figures to stay out of such issues as how to create a physician note or observation electronically. Leavitt says that's where vendors should differentiate themselves. Order entry and retrieval of results could go in one direction or another, with strong forces pushing to expedite requirements for physicians to enter their own orders. Other experts point out that the hardest thing to make doctors do is enter their own data, while the easiest is to get them to look up the information, he says.
If done right, the certification effort will result in not just a set of requirements but also a road map with milestones for IT companies and other players such as standards organizations, Leavitt says. For example, the focus in 2005 could be on required IT functions, leading in 2006 to frameworks for making physician IT systems interoperable with each other and with other systems for hospitals and health plans.
"When you put that stake in the ground like that, it's good for vendors," he says.