Monday, September 21, 2009

To Wait or not to Wait?

I'm often asked by clinicians and hospitals if they should wait to purchase an EHR because of the uncertainty regarding meaningful use and certification.

I tell them to move forward now.

Meaningful Use is complete for 2011 and you'll find the finished matrix online.

Although the HIT Policy and Standards Committees only make recommendations/advise the Office of the National Coordinator and HHS, I believe that the regulations issued in the next few months will follow the spirit of the Commmittee work.

Here's my understanding of the events of the next few months:

1. In mid December, CMS will issue a Notice of Proposed Rulemaking (NPRM) regarding meaningful use, then provide a 60 day public comment period. A final rule on meaningful use will be issued in the Spring.

2. In mid December, the Office of the National Coordinator will issue an Interim Final Rule (IFR) regarding certification criteria and standards. A public comment period of 30-60 days will follow and the final rule on certification criteria/standards will be issued by Spring. This is law the day it is issued (unlike a NPRM which is proposed law). While the IFR will solicit comments, the Secretary is not required to respond to the comments or make changes based on them. Hence, for all practical purposes, the industry should treat the IFR as "final" even though HHS reserves the right to make subsequent changes The certification criteria in the IFR are likely to emphasize privacy/security and data exchange standards. They will replace previous CCHIT criteria, but in the interim you will be well served to pick vendors that have passed CCHIT regular criteria and the additional CCHIT Meaningful Use criteria.

3. In mid December, the Office of the National Coordinator will issue an NPRM defining the Certification process. A public comment period of 30-60 days will follow and the final rule on the certification process will be issued by Spring. CCHIT will likely be one of several conformance testing organizations, coordinated by NIST, that will certify products using the new ONC criteria.

Thus, completely clarity in the form of rulemaking will be available in the Spring.

However, the longer your wait to get started, the more challenging it will be achieve meaningful use in practice by 2011. Also, it's important to get vendor commitments and hire staff now before the real competition for resources begins.

Start by purchasing a fully functional EHR or a hosted solution that was certified using previous CCHIT criteria. Also, ensure it supports data exchange. The interoperability goals for 2011 are likely to be

Lab results delivery
Claims and eligibility checking
Quality & immunization reporting

so, you'll want to be sure that the product or the product plus third party services support those functions.

If you're a hospital organization, develop a governance structure for prioritizing projects, a budget, a training plan, and a communication plan. Spring will be here soon and any ambiguity will be resolved.

Thus, I think we can predict what meaningful use and certification criteria will be based on existing HIT Policy and Standards Committee work, so you should move forward now without delay. When 2011 stimulus payments begin, you'll be thankful you had the time to prepare.


David said...

Good post! As for 2011 MU interoperability goals: don't forget clinical summary exchange among providers for coordination of care, and with patients for patient engagement.

Amanda Parsons said...

John- great meeting you last week. If interoperability with labs is likely to be a key factor for 2011, do you have sense of what carrots/sticks are going to be employed to ensure that the lab vendors participate? Right now, some of our labs are balking at the low revenue from the smaller primary care practices, and it's hard to get them to commit the resources needed to create these bidirectional interfaces (order and result). In addition, many don't bother to fully LOINC map their compendiums (because you only need LOINC for resulting- they have your business by then). I do worry that we're going to need the lab vendors to significantly increase their capacity to build & test interfaces, and will also need to do something about the CLIA rules that aren't suited to electronic interfaces. What are your thoughts?

John Halamka said...

This is a thorny problem, but we should hope that hundreds of thousands of meaningful use purchasers requiring new standardized interfaces will change this dynamic. The standardized interfaces will cost a small fraction of previous costs, making it easier to support small volume installations.

Unknown said...

Great information. I went to the meaningful use grid and have been studying the 2011 Objectives and Measures. Can you tell me how literally to interpret the ordering phrase "entered directly by physicians through CPOE"? I'm assuming that if direct keying by physician is required, instead of RNs or other staff, that it's intended to eliminate errors. Can you confirm this?

John Halamka said...

You are correct. The definition of CPOE is "from doctor's brain to patient's vein" with no intermediaries along the way

John Lynn said...

Thanks for sharing the timeline. However, I do disagree with you that people should be selecting and implementing an EHR now. There's no rush to do this. I can agree that users should start reviewing the various EHR vendors and technologies that are available so that they are familiar with the choices that exist. However, it's premature for those users to actually select and implement an EHR.

Your suggestion of choosing a CCHIT certified EHR is also off base. The fact is that not even the onerous CCHIT certification criteria meets the meaningful use matrix that you reference. So, that will change and it's likely that not all CCHIT certified EHR will achieve HHS EHR certification (which is what really matters for the $$).

Instead, the wisest counsel that can be given to providers is to select an EHR based on which EHR software will best meet their business needs. If they do that, then whether they're able to get the EHR stimulus money or not they'll be happy with the decision they make. The EHR stimulus money will just be a nice bonus if it all works out well.

Christopher Sprowl, MD said...

I agree, don’t wait for a definition of meaningful use. As you point out the definition is becoming clear enough from “official” sources. I would also make the point that if we take a patient-centered approach to defining meaningful use it be: any of my information, any of my providers need, any time, any where. The technology needed to support this definition exists: fully functional EMR to keep and share a complete medical record, preferably with all the patient’s providers sharing a single EMR record on an enterprise database in the patient’s own community and linked to a health information exchange for sharing information on a broader basis. So the definition is known and the technology exists. Further, President Bush and President Obama have made it clear that they want every provider to use a fully functional EMR and they want it to happen soon. ARRA incentives are front loaded with penalties for non-use beginning in 2016. CCHIT certification changes regularly and is moving in the direction of creating criteria that only fully functional EMRs will meet. The “official” definition of meaningful use will also likely push us toward a fully functional EMR. Payers will require EMRs just like they require electronic claims submission. HIT projects take time. They should be started ASAP. Otherwise providers risk loss of incentive money, penalties, distracted resources, re-doing their projects, non-compliance with payers, not to mention benefits patients might derive from them using fully functional EMRs in a meaningful way. Moreover, providers need the decision support and data management capabilities of an EMR to meet the demand for demonstrable value and will need it to participate in the coming ACOs. To wait is perilous. Waiting could mean the end of your practice.

Christopher Sprowl, MD
Healthcare Value Applications, Inc.

Deborah said...

I understand that being an "eligible provider" is dependent upon whether a physician is hospital or office based regardless of who employs him or her. What is not clear to me is whether it matters who paid for their EHR. If the physician is using an EHR provided and paid for by a health system, is the physician still eligible for funds under ARRA? In that case who would get the payment?