Wednesday, February 14, 2007

Is CCHIT becoming the Good Housekeeping Seal of Approval?

The Certification Commission on Health IT recently announced that, in 9 short months, it has certified 55 EHRs. This means that 25% of the EHR market is now certified.

Maybe it's just me, but I wonder if this is an indication that we've set the bar too low. Don't get me wrong -- the CCHIT is driven by people who are way smarter than me on this stuff, and they're doing excellent work. And clearly, the market has suffered from a lack of standardization.

Yet, I had expected (perhaps naively) that CCHIT certification would help drive an industry shakeout. But as I see the numbers and scan the list of vendors who've made the grade, that's looking less likely (go here to judge for yourself). Rather, this is looking more and more like the type of ubiquitous certification - UL and Good Housekeeping come to mind -- that provides a broad level of comfort around very basic criteria that define minimum capability, but don't do much to separate the wheat from the chaff.

There is an argument that the UL-type of very basic standardization is market-expanding (and therefore, good). In markets where consumers have a hard time distinguishing among products on their own (due to product complexity, for example), strong brands will dominate unless other sources of trusted information or assurance are available. For example, I can't tell whether the wiring in my toaster is safe, but the UL label assures me that it's been built according to standards that minimize safety risks -- a valuable assurance that we've come to take for granted in the US and Europe. (I lived in India for awhile where, after a few good electric shocks, I learned to appreciate the safety that this type of certification provides.)

A recent Business Week article argues that CCHIT's approach to this type of market-expanding certification is changing the EHR industry:

EHRs require hardware, software, databases, networks, and, at their most advanced, picture archives of radiology and pathology images. Specialized health-care IT vendors such as Cerner, McKesson, Eclipsys, and Allscripts previously sought to establish widespread EHR networks, with limited success. The new federal government initiatives are reinvigorating the field.

Even as these companies renew their efforts to tap the market, they face increasing competition from deep-pocketed first-time entrants. These include the world's top three diagnostic imaging companies, Siemens , General Electric, and Philips Medical Systems, a unit of Philips Electronics.

It's a tempting argument -- but I think it's wrong. The BW article doesn't recognize that the ambulatory EHR market is different than the hospital market, in part because BW has the usual biz pub bias toward reporting on publicly-traded companies. (I especially like their claim that GE is new to the EHR field.)

Of course, there is value in ubiquitous, trusted certification. However, when it goes too far it undermines its own raison d'etre. Neighborhood Watch signs are a good example. These signs are everywhere, which suggests that they have no effect whatsoever. I'm guessing that once every neighborhood got "certified", it just brought everyone back to square one on crime, because the signs were no longer effective tools for distinguishing one neighborhood from another.

In my view the biggest problem in the EHR market isn't that there are too few entrants, but rather, it's that there are too many. There are over 200 EHR companies in the country today, most of them privately-held; pruning, not fertilizing, is what the market needs to grow. A certification process that gives everyone a seal of approval won't solve that problem.


Anonymous said...

Well Said. Totally agree.

Elena Postal said...

Conceptually, the CCHIT may be an excellent idea, but it may also be keeping smaller vendors with high quality products out of the market.

The CCHIT submission fee tops $28,000 and is followed with fees in subsequent years after certification is awarded. The cynics contend that the CCHIT is simply an effort by HIMSS to support the medium to large vendors that make up their organization.

Whatever the case, small physician practices find it difficult to commit to the $30K (or more) plus implementation that these certified products demand. So unless the Blue Cross Blue Shields of the world plan to replicate their $50 million project hundreds of times over, physicians will need lower cost offerings, offerings not likely to come from the big vendors who seem more interested in larger contracts.

Not mentioned here or often in other circles is the plan to submit the Veteran's Administration's
Vista Office EHR (VOE) for CCHIT certification this month. VOE is a *FREE* OpenSource package distributed as a ready-to-go complete stack via the Freedom of Information Act. It is derived specifically for smaller clinical environments from the VA's comprehensive VistA system which is the longest operating and really only fully connected EHR in existence. It was awarded Harvard's Innovation in Government Award in 2006.

Perhaps VOE is exactly what we need to bring the small practices into the 21st century. Of course, we can guess how many of the vendors might feel about this effort...

Micky Tripathi said...

Hi Elena,

Thanks for the great comments.

I was sympathetic at one time to the cynics' argument that CCHIT was basically captured by larger vendors as a way to keep out others. However, after seeing the results of CCHIT's efforts to date, I've come to the opposite conclusion -- I think it's in danger of creating a process that doesn't turn anyone away.

I'm not worried about their submission fee. Any company that can't afford that probably doesn't have the resources to develop a really good EHR. My personal bias is that only the very good EHR systems really offer the value that justifies the effort and change required to get them in place. And it takes real development resources to put together a sophisticated EMR/PMS system, and real support resources to provide the ongoing support required to keep them going.

Finally, on Vista Office, I'm not as sanguine as you are on its prospects, but I'd love to be proven wrong. The real cost in EHR fees isn't the software license, it's the training, maintenance, and support. Vista might succeed if a Red Hat-type of company steps in to provide the professional services and version/upgrade management around the product, but then it's cost is going to be in the same range as the other vendors. Anyway, as I said, I hope you're right about this!


Foster Kerrison said...

This is an interesting discussion, and I am interested to know if MAeHC are planning to certify or otherwise advise the public, (or physicians for that matter), on what systems satisfactorily met their evaluation standards and why.

I believe that the reluctance of many physicians, (over 90% right?), to invest in EHRs has to do with the lack of really effective evaluation models. The individual physician does not have the tools or skills to make a good decision on an effective EHR. That is the domain of healthcare IT professionals, (sometimes known as Healthcare informaticians), who have the skill sets to apply evaluative techniques to these products.

The literature, (see PUBMED), is limited on these evaluation models, although Charles Friedman and Jeremy Wyatt have a useful book, "Evaluation methods in biomedical informatis," Springer, 2006, on the subject.

I agree that setting the bar too low may be a useful political success strategy, but it does not serve either the patient or the physician.

Foster Kerrison.