In 2004, David Brailer, then the newly designated head of the newly created Office of the National Coordinator for Health Information Technology at HHS, said out loud and in public that the low level of physician adoption of electronic health-record systems was a serious national problem his office would address.
Adding pressure, in the executive order that created Brailer's position, President George W. Bush set a goal of making electronic health records available to most Americans in a decade. But if doctors didn't have EHRs, how could patients have electronic records?
Brailer concluded that one of the barriers to EHR adoption was a physician's fear of buying a bad system. He called for a private-sector organization to create the equivalent of an Underwriters Laboratories or Good Housekeeping seal of approval for EHRs.
That same year, three not-for-profit organizations, the National Alliance for Health Information Technology, American Health Information Management Association and Healthcare Information and Management Systems Society, founded and grubstaked the Certification Commission for Healthcare Information Technology.
The following year, HHS put some money where Brailer's mouth was and awarded CCHIT a three-year, $7.5 million contract to fund a testing and certification program for healthcare IT systems.
The initial contract ran out Sept. 30, but the commission is not bereft. CCHIT reports that a recently awarded contract extension valued at $1.4 million will help keep the lights on through April 19, 2009. But then what?
One of the many questions facing the incoming Obama administration is which Bush IT policies and programs to jettison and which to keep. Though the appointment has not been announced, Former Senate Majority Leader Tom Daschle has reportedly accepted Obama's offer to be HHS Secretary.
Physician Mark Leavitt was director of ambulatory care at HIMSS in September 2004 when he was named chairman of the commission, a position he holds today. Leavitt said that the commission has weaned itself off total dependence on federal support by charging IT vendors fees to certify their products.
"This year, we're at the point of somewhat close to half of our funding is already self-sustaining, coming from certification fees," Leavitt said. "Every year we've been able to grow the proportion of funding. We expect to be able to keep growing that."
Not surprisingly though, Leavitt said, "We think it is appropriate having a government (funding) component."
At this date, CCHIT lists on its Web site 52 EHR systems from 45 companies certified within the past 12 months that are thus eligible for subsidy by hospitals under federal Stark and anti-kickback waivers. Dozens more EHRs have been certified in earlier testing rounds, which began in 2006. Since then, CCHIT also started testing and certifying components of an inpatient EHR. The site lists 15 inpatient systems that passed inspection last year and this. The commission also has certified one "enterprise" and three emergency department EHRs it tested this year. It is testing ambulatory EHRs with "extensions" for child health and cardiovascular medicine this year and has plans to test other medical specialty extensions as well as personal health records.
According to John Morrissey, communication manager at CCHIT, a host of IT incentive programs in which CCHIT-certified EHRs qualify have sprung up since the commission began certifying IT systems. Thus far, 55 physician EHR subsidy programs representing 147 hospitals were created to avail themselves of federal waivers to Stark and anti-kickback laws. Another 23 public and private IT incentive programs either require or "strongly favor" certification, according to Morrissey, while 21 programs don't require certified systems but were included in a list posted on the CCHIT-affiliated Web site EHR Decisions to show the sweep of incentive programs being developed. The total dollar value of all of these incentive programs is an estimated $720 million and the total number of receiving or offered incentives is more than 47,000, numbers Morrissey says are "very conservative."
As CCHIT officials await word about future federal funding, though, "We're also going to very careful about our expenses," Leavitt said.
Randall Oates is a physician who is founder and president of SoapWare, a Fayetteville, Ark.-based developer of a CCHIT-certified EHR for office-based physicians. Oates is no fan of CCHIT, but acknowledges "even a bad certification is better than no certification, thus we have to participate."
Oates said the more than 200 testing criteria that CCHIT requires every vendor to pass puts an unreasonable burden on software developers, add to the expense of the systems and makes them unwieldy to end-user, primary-care physicians.
"I bet we've spent a quarter of a million dollars in development costs just to get around the functionality that is being forced into the system," Oates said. He argues that more than half of the functionality CCHIT requires could be moved out of the core system requirements into extensions.
Oates said that to make EHR systems usable, they have to be tailored "to make them suitable to the various niches in healthcare," Oates said. "You can't have one-size-fits-all. Things that could be straightforward and easy have to be bloated and cumbersome. It really has hurt the progress for adoption."
What CCHIT and the government need to get behind, Oates said, is what he calls "affordable interoperability" using Internet-based messaging.
"What they're offering doesn't give the buyer that. In fact, you could argue just the opposite," he said. CCHIT's reliance on the Health Level 7 messaging and the Continuity of Care Document standard "is like asking families to get a freight train to go to the grocery store," Oates said. "It is way too complex and cumbersome."
Oates predicts that eventually, "the Internet will supersede this craziness in this industry. It's inevitable."
In the meantime, the commission would do well to bring in some physician experts and certify EHRs on usability, which Oates argues is as critical to physician adoption as functionality. Cumbersome systems have led to the bulk of EHR de-installations, Oates said.
"It doesn't matter how many features and functions a system has if it's unusable," he said.
Physician William Bria, chief medical information officer for the Shiners Hospitals for Children system and chairman of the Association of Medical Directors of Information Systems, said CCHIT "didn't accomplish any major improvement in EHR adoption," but its government support contract should be renewed anyway. If Oates said CCHIT caused vendors to cram too much functionality into their system, Bria finds fault that the commission hasn't yet forced vendors to add enough functionality, particularly in clinical decision support, or CDS.
"They did serve an important EHR purpose in setting a cellar, a minimal standard that now should be escalated fast to include much more CDS," Bria said.
In addition, Bria said, CCHIT needs to force vendors to produce value in improving safety and quality "instead of being satisfied with minimal functionality that the vendors want us to stick with for their own reasons."
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