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April 13, 2011 News 5 Comments

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The EHR Herd, Part I: Is Certification a Helpful Credential for EHR Purchasers?
By Reefdiver

Would you buy a refrigerator that hasn’t been certified by UL? Would you buy a cut of meat at the supermarket that lacks the USDA stamp of approval? Would you purchase an automobile if it was not certified as meeting the minimum government standards for safety?

On the other hand, does the UL certification tell you which refrigerator is right for your kitchen or family? Does the USDA stamp tell you whether the skirt steak or the filet mignon is a better fit for the meal you are planning? Does the EPA approval tell whether the Smart Car or the Durango XLT is better for your vehicle needs?

As of today on the ONC site, there are 375 EHR products certified by all of the ATCBs combined for the ambulatory market alone, of which 262 are Complete EHRs. (Note: I started writing this two days ago and both of these numbers have gone up by significant amounts in the interim, with no apparent end in sight).

Does anyone else find it absolutely astonishing that that many products can pass the certification criteria that meets government specifications for allegedly being able to help providers meet Meaningful Use (MU) criteria? And that the number continues to grow each week? How hard can these standards of certification be if every product passes?

More than 30% of law school graduates fail to pass the law boards each year. Series 7 exams for new stockbrokers have a pass rate that is less than 50%. CPA exams are notorious for being difficult to pass, with the national average being about an 85% failure rate. Years ago, more than 50% of the pilot trainees in my military flight training class failed to earn their wings during the 15-month training program – they were washing out right up to the last weeks of training.

Is EHR certification getting to be like passing the UL test? As long as the product doesn’t produce a massive shock, it passes? A urine test must be statistically harder to pass than EHR certification. 

EHR certification is almost becoming a rubber stamp. Shouldn’t there be some failures with this many product applicants? Or, does certification not measure some critical differentiators, like usability? Given the 50% implementation failure rate so commonly quoted, maybe it’s just a demonstrative example that with technology, it’s much easier to certify functionality than it is to certify usability or practice-appropriateness.  

What other industry can you think of where this situation — hundreds of software vendors with government-certified products for one single class of end users, medical practices — is possible? Software for airline reservations? Enterprise software? Financial planning, spreadsheets, word processing, inventory control, hotel management, software for law firms, tax preparation software?  

Most of these huge software segments have no more than a handful of competitive software products. More than 300 certified software products for EHR, with more coming each week. Sure seems like a lot. Will probably lead to consolidation problems later!

Should the herd be thinned out, or is it better to have so many products certified? The number of choices is daunting for providers, like the cereal aisle at the market. It will be hard for the EHR market to support this many vendors, but a free enterprise system can often result in two doctrines that come into juxtaposition: survival of the fittest (vendors) and caveat emptor (providers). Does certification help either party more?

The other half of this delicate equation is the providers and practices. Their role is to pick an EHR and show Meaningful Use. Most vendors guarantee the desired outcome, but what is the fine print saying and are providers aware of it? 

With more than 300 certified products to choose from, how do providers pick one that is really right for their practice and specialty? The advice being given out there is pretty bland and not very useful for decision makers as far as I can see. Big vendors are not necessarily better than small ones. I’ll offer some thoughts on that later in the week in Part II of this, should anyone be interested.

For now, I hope some providers will respond to my comments. I’d love to hear how you feel about all the EHR products that are being certified and how is it helping you to choose whether and if to purchase one. And,  how you are going about finding one that really fits your practice and workflow best.

Comments 5
  • The UL listing example provided here is a good one. UL certifies that a product meets certain requirements with respect to certain features of how it operates. It doesn’t say anything about whether one refrigerator is better than another. Similarly, the ONC-ATCB certification indicates that an EHR meets ONC requirements with respect to meaningful use. Again, it doesn’t measure one EHR against another.

    Neither UL, nor the ATCBs indicate how many systems fail their tests. We simply don’t know. But then again, nether UL nor ONC-ATCB certification are meant to compare products or vendors against each other, or against the industry as a whole.

    Certification is a useful credential when results are used for what they were designed for. It is only when you expect more from certification than what it intends that it will fail to meet expectations.

  • MU certification is not a product specification, warranty, or fitness-for-use determination. It is only a line-tiem on what should be a lengthy list of requirements that a purchaser should have. The purposes of that line-item are to gain a subsidy for the purchase price and, downstream, to avoid reimbursement discounts.

    If the MU certification had directly referenced the prior HITSP and HISPC work, the original CCHIT criteria, the underlying IHE profiles, and the relevant standards thay are all based upon… well, then it would be somewhat closer to robust use cases, functional specifications, validation critieria, and key information for a fitness-for-use evaluation. While this may have ruled-out a number of non-robust products and raised a hue & cry from some standards-body politicians, it was all developed in a very transparent manner and publicly vetted. Criticism that it’s hard to do is disingenuous. The only thing that was sorely missing, in my opinion, was sufficient input from small providers and health care consumers — yielding opportunities for future improvements, not reasons to discard the work.

    So it amazes me that this prior work, already paid for by government funding and many industry volunteers’ time, is so underutilized by MU criteria. We have spent more time and taxpayer’s money reinventing uniform wooden wheels for something that demands durable inflatable tires.

  • Perhaps another way to look at the issue: If an electrical appliance does not have a UL listing, does that dissuade a consumer from purchasing? Probably, or at least for some consumers it does.

    I’ve purchased UL listed products that shorted out and fizzled upon first use or that didn’t perform to the packaging promises. I imagine plenty of similar experiences for many purchasers of “certified” EMRs.

    For a provider, ONC-ATCB certification provides liitle value, if any, in helping to choose the right EMR for their particular situation. EMR selection continues to be an obnoxious process and certification has no real impact upon that.

    Virtually every EMR available can provide digital function and most now meet “Meaningful Use” functionality criteria. But, workflow is really the prime determinant to end user satisfaction and MU has nothing to do with workflow. (Workflow is so danged difficult to measure and so variable from setting to setting, provider to provider.)

  • One of the reasons there are SO many certified ONC-ATCB products coming out of the woodwork that HIT generalists or hospital-centric watchers are shocked at that is that the ecosystem of specialty EMRs for providers was invisible to them. Most specialty EMR vendors, despite having health market share in their specialty, do not showcase at general health IT events, but instead have booths at their specialty medical association shows. In our specialty, we have twenty plus shows we go to a year and we don’t even go to the smaller events. Add in natural growth as our clients add new locations and new doctors and you have a very healthy market share growing each year. Our providers, many of whom have been using a PMS system for more than 15 years and a EMR for 10 years, have been very quick to go for the ARRA incentive and like our competitors, we went for the ONC-ATCB certification. Since our providers are usually not allowed to give immunizations or would never do so, have been rejected from syndromic surveillance by public health who believe their specialty is inappropriate for submission, and usually order one or two lab tests a month only if a PCP is unavailable to order it, much of what we did will only be used for certification.

    We have been eagerly awaiting CCHIT certification for our domain, but it was pushed off the schedule. IHE just got around to formulating profiles for our domain this year and the equipment vendors have just begun to add DICOM support in the past year or so. Since our doctors take ten years or more to pay off their equipment investments, we’ll be supporting non-DICOM test equipment for at least another 15 years.

    The outside HIT world needs to understand that specialty domains have workflows and needs totally different from PCPs and hospitals and stop diverting resources away from them. Instead of reinventing wooden wheels for PCPs, perhaps that time should have been better spent inventing the wheel for everything that’s not a car – there’s a lot of mopeds, scooters, motorcycles, bikes, electric carts, etc out there that perform a vital healthcare role and have no standards to rely on.

  • While it’s true that ONC-ACTB certified EHRs are now a dime a dozen, there are other certifications that can help providers decide which solution best meets their specific needs. Providers who serve Medicare and Medicaid patients should seek vendors certified for CMS’s Physician Quality Reporting System (PQRS). Providers who serve HIV/AIDS patients should seek a product that has achieved Ryan White Services Reporting System (RSR) certification in order to meet reporting requirements without purchasing additional software. Though the market is similarly saturated with CCHIT certified vendors (separate from ONC-ACTB certification through CCHIT), providers should seek a vendor who has achieved both types of certifications.

    It’s also important for providers to consider when the vendor achieved certification—those certified in the first round are the most ideal. If a vendor wasn’t certified in the earliest round, they likely were in one of two scenarios; they either rushed to throw together a product in the last 12 months or they’ve had a certified product for a long time, but couldn’t get their act together to pass certification. To weed out the many certified EHRs, providers should seek a vendor with a depth of certifications and should closely inspect their date of certification in order to ensure that they are getting a quality solution.

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