Technology: Should Your EMR Be Certified?

Still waiting to buy an EMR? A recently formed nonprofit organization thinks it’s come up with a way to help you sort the technological wheat from the chaff.

But does the stamp-of-approval process devised by the Certification Commission for Healthcare Information Technology (CCHIT) really make life easier for busy practices - or does it, as some say, provide you with misleading information while unfairly excluding vendors whose products might be perfect for you?

The commission’s certification process aims to remove the risk that a newly purchased EMR won’t be able to perform all the functions the sales rep promised. It also hopes to guide physicians to systems that are capable of measuring and reporting quality indicators for pay-for-performance incentive programs.

Though launched in 2004 with seed money from several associations, CCHIT is private, and the certification process is voluntary. An EMR system earns certification only after a team of experts, each including at least one practicing physician, puts the software through its paces. In its first year, the commission has certified more than 80 products.

In 2007, software is deemed certified after 247 criteria are inspected in 315 test steps for functionality, interoperability, and security. In the functionality area, ambulatory EMR systems approved in 2007 must be able to complete tasks in 40 categories (see below). CCHIT revises and updates its test criteria annually. Standards and required functions are based on input from practicing physicians, vendors, payers, and technology experts. You can visit CCHIT’s Web site for a list of the ambulatory electronic health record products certified by CCHIT thus far.

The commission next plans to outline standard functions for EMRs used in children’s health, cardiovascular specialties, emergency medicine, and other specialties. Next year it will tackle prescribed functions for interoperability of EMRs that are networked to one another.

Not the silver bullet

Should you limit your EMR search to certified products only? Not necessarily. Certification doesn’t assure that a system is user-friendly or affordable. Nor does it tell you that the company won’t go out of business next week or just has lousy customer service.

“There’s value to what the commission is trying to do, but it will not be the silver bullet that guarantees that any physician practice buying a system from a certified vendor will have no problems implementing or using that system,” says Steven Lazarus, president of Boundary Information Group in Denver. “Certification reduces the risks, but it doesn’t eliminate them.”

Adds Nantucket, Mass., family physician Craig Bradley, “The way I understand it, CCHIT certification assures you certain things will be available, but it doesn’t necessarily guarantee you that the way they got the system to meet those criteria was done very efficiently.”

In other words, you’d still be wise to do your homework before signing on the dotted line for that new EMR. But you may be able to narrow the list a little faster now.

Rationale for certification

Conscientious EMR shopping often means talking to dozens of vendors, ringing up colleagues, lurking on user groups’ listservs, and perhaps hiring a consultant. With more than 200 firms claiming they sell a fully functional EMR, the process may feel like it’s taking forever. For Bradley, it took nine years.

“I was shopping for an EMR basically from when I got out of residency in 1995 to 2004, when I finally bought one at my previous practice,” he says of his eClinicalWorks EMR. “Part of it was waiting for the products to mature. Now, what you get in terms of functionality is so much more cost-effective. But if CCHIT was around then, it would have saved me a lot of time.”

While the quality of EMRs for ambulatory practice has certainly improved since the mid-1990s, the market has until recently been a bit, well, moribund.

“If the marketplace was well developed and vigorous, you might ask, ‘Why do we need certification?’” says Mark Leavitt, a Hillsboro, Ore., internist and CCHIT president. “But what we had was basically a stalled marketplace, and that is where the right catalytic intervention - certification - can help get things going.”

Studies seem to back that up. The National Center for Health Statistics found last July that fewer than a quarter of office-based physicians owned a full or partial EMR in 2005. Only 9.3 percent used systems that had all four of the functions that many experts consider basic to an EMR - e-prescribing, test ordering, test results reporting, and physician notes.

Leavitt, who started an EMR firm of his own in the 1980s, says a valid third-party certification process can reduce physician anxiety and costs. If more physicians buy EMR software, vendors should be able to spread their marketing and sales prospecting costs out over many more units. Ultimately, EMR prices should drop, he says.

ROI disconnect

Another roadblock to wider physician adoption of the technology has been what Leavitt calls “the ROI disconnect” - the economic benefit that health information technology mostly accrues to insurance companies, employers, and patients who can lower their costs to purchase care. Yet doctors must bear 100 percent of the cost to buy, implement, and maintain the systems.

By setting up a verifiable national certification process, Leavitt and others hope that payers will loosen up the purse strings to offer more grants or richer pay-for-performance program bonuses to qualifying practices that use certified systems.

“That’s probably the more powerful mechanism: reversing that ROI disconnect and bringing that money back across to the physician,” Leavitt says.

The response so far from the nation’s payers has been slow.

Steven E. Waldren, a family physician and director of the Center for Health Information Technology, says it may be too soon to expect a flood of new incentives and declining costs.

“The wide-scale incentives are not there yet,” says Waldren, whose center is an arm of the American Academy of Family Physicians, a primary backer of CCHIT. Payers might just be waiting for broader EMR adoption by physicians before offering more significant incentives, he says.

Certify, schmertify

While Leavitt and others see the certification process leading to broader acceptance of EMRs and ultimately lower costs, others see it as the hand of big government and big industry squeezing out smaller vendors. Where that path leads, say critics, is not a level playing field where vendors large and small offer affordable, functional EMR products. Instead, says Jonathan Bertman, a Saunderstown, R.I., family physician and CEO of Amazing Charts, the growing menu of certification requirements will make systems more complex, less user-friendly, and more expensive.

“I’m all for standardizing what an EMR does,” says Bertman, whose firm targets small physician practices for its low-cost software. “I like the concept of certification. Interoperability is crucial. But [certification] is micromanaging and adding requirements, feature after feature, that may not make sense.”

Bradley also worries that certification standards may have unintended consequences.

“I’m not against CCHIT, but it would be a shame if we have such an unequivocal standard that no one would be able to innovate or start in the market without a huge amount of capital,” he says.

Leavitt argues that the $28,000 fee to apply for initial certification should not be a barrier for even small vendors.

“We believe the fees are quite modest compared to what other types of certification might cost and also compared to the benefits,” he says.

For Bertman, whose systems sell for a modest $1,000, recouping the commission’s application fee would mean finding 28 new clients. While he fumes about the certification process and its costs, he says he’s resigned to apply for certification. He’s already adding several commission-desired features to his system, which he expects will increase its price.

“I believe CCHIT certification is a good thing, and I think a large part of the marketplace today agrees,” says Bruce Kleaveland, a Seattle-based health IT consultant and coauthor of “The Tech Doctor” column in Physicians Practice. “But there’s no question that CCHIT represents a certain view of the world - and it is also the government’s view - which is that, one, more people should have electronic health records; two, electronic health records should interoperate with each other; and, three, electronic health records should easily provide data to third parties, like the government and payers, so they can assess cost and quality.”

What it isn’t

Think of the certification commission as more comparable to the Underwriters Laboratory, which sets pass/fail standards, than to the Consumers’ Union system of rating products.

“User friendliness is not possible to rate fairly now, and perhaps never [will be],” Kleaveland says. “Ultimately, the market is what measures a system.”

CCHIT also does not investigate or rate an applicant’s financial viability or after-sales service.

Lazarus cautions that even the latest CCHIT-issued functionality requirements may not reveal whether you are buying what he considers a fully functional EMR. For example, systems certified in 2006 and 2007 were not judged on whether they interface with the billing system to check coding, though CCHIT will call for more of those functions in the near future.

Besides, says Lazarus, “just because something is certified doesn’t mean it is the right system for your practice. It reduces the risks but doesn’t eliminate them.”

Rosemarie Nelson, an IT consultant with the Medical Group Management Association, suggests becoming a smarter shopper. Get the scripted scenarios the commission uses to test vendors and modify the scripts to give the vendors on your shortlist a better workout, she says.

“Create a scripted patient exam for the vendor to follow when they demo the product,” she says. “Otherwise, it becomes just a show of bells and whistles instead of showing you how it would work in your practice.”

No argument on that from Joel Andersen, who is vice president of marketing and business development for Purkinje, whose CareSeries EMR has been certified.

“Infuse yourself into the vendor’s Web demo and into using the software,” says Andersen. “Don’t let them just do a canned demo. Take control of the situation.”

Waldren suggests online forums from the various specialty associations. For example, members of the American Academy of Family Physicians can find the academy’s EMR e-mail discussion list at the online Center for Health Information Technology, where more than 1,000 physicians discuss personal experiences with EMR deployment. There is also a Physician Product Review, which rates EMRs on quality, price, ease of use, support and other criteria.

And then there are independent EMR software ratings and reports, easily accessible online. MGMA consultant Rosemarie Nelson has compiled a list of the sites that offer these products and has critiqued them (see below).

Waldren says it’s too early to tell what affect certification is having on the market, but one thing’s for sure: Business is booming. Academy members tell him that they are now waiting three to nine months for busy EMR vendors to install new systems.

The spread of pay-for-performance plans and other funding sources for medical practices, combined with last year’s slight relaxation of the Stark rules to allow hospitals to donate certified systems to medical practices, better pricing, and a growing awareness of what certification is - and isn’t - may just give more physician practices new confidence in their EMR shopping skills.

Bob Redling has written on practice management topics for more than 10 years. He has served as practice management editor for Physicians Practice, Web content editor and senior writer for the Medical Group Management Association, and a speech writer for the American Academy of Family Physicians. He can be reached at editor@physicianspractice.com.
This article originally appeared in the July/August 2007 issue of Physicians Practice.