President Bush called for widespread use and accelerated adoption of a personal electronic health record (EHR) record for every citizen by 2014 to improve the quality of care and facilitate communication between providers and patients. As federal EHR initiatives intensify, practices are asking whether to wait to invest in an EHR product? “No,” says Mark Leavitt, Chair, Certification Commission for Healthcare Information Technology. “The time to transition from paper records is now!” The good news for practice administrators is that soon EHR products will be certified for specific functionality, interoperability, and security requirements in keeping with the government’s national health information technology (HIT) adoption initiatives.
Source: US Department of Health & Human Services (www.hhs.gov/healthit/ahiccharter.pdf ).
The National eHealth Initiative
The centerpiece of the EHR initiative in the United States is a national health information network connecting millions of EHRs for American patients. Advocates of EHRs claim that the use of such records could: shrink US medical costs by hundreds of billions of dollars annually, reduce the estimated 100,000 lives lost through medical errors, and improve the general quality of patient care.
To that end, the President’s Executive Order (EO) 13335 established the Office of the National Coordinator for Health Information Technology within the Department of Health and Human Services (HHS). The coordinating group fosters collaboration with numerous federal agencies already involved in HIT and has set forth an aggressive timetable starting in 2004 to develop and implement an EHR system that will:
- Ensure interoperability—the sharing of clinical and administrative data across multiple health care settings and technology platforms.
- Reduce medical errors through delivery of evidence-based care.
- Reduce health costs resulting from inefficiency, medical errors, inappropriate care, and incomplete information.
- Promote increased consumer choice through increased availability of accurate information on health care costs, quality, and outcomes.
- Improve coordination of care and information among hospitals, laboratories, physician offices, and other ambulatory care providers through the secure and authorized exchange of health care information.
- Ensure the security and privacy of patients' individually identifiable health information.
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Leading the Way—the American Health Information Community
As a part of this collaboration, the EO launched the American Health Information Community (AHIC) with broad-based representation from providers, vendors, government HIT leaders, purchasers/payers/coalitions, standards development organizations, and health care consumers.
AHIC members were tasked to focus initially on EHR interoperability for physician offices and to deliver specific recommendations to HHS Secretary Michael Leavitt concerning how to:
- Protect health information through appropriate privacy and security practices.
- Harmonize industry-wide HIT standards.
- Develop an Internet-based nationwide HIT network that includes information tools, specialized network functions, and security protections for interoperable health information exchange.
- Accelerate interoperable EHR adoption across the broad spectrum of health care providers.
- Develop compliance certification and inspection processes for EHRs, including infrastructure components through which EHRs interoperate.
- Identify and prioritize specific uses for which HIT is valuable, beneficial, and feasible, such as adverse drug event reporting, electronic prescribing, and lab and claims information sharing.
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Why Certify EHR Products for Physician Offices?
Practices may be frustrated and confused by EHR industry claims and find it difficult to judge product suitability, quality, interoperability, data portability, and security. “Certification will help practices to distinguish among over 200 EHR products on the market,”says Sue Reber, Communication Director for the Certification Commission for Healthcare Information Technology (CCHITSM).
In October 2005, HHS awarded a contract to CCHIT, an independent third party, to develop ambulatory EHR certification criteria and an inspection process intended to:
- Reduce the risk for providers’ HIT investment by ensuring functionality, interoperability, and security.
- Ensure interoperability (compatibility) of HIT products with emerging networks.
- Enhance availability of HIT adoption incentives from purchasers and payers.
- Protect the privacy of personal health information
Practices will benefit from the processes CCHIT has created to inspect products. CCHIT encourages vendors to prepare and apply for certification, tests and manages vendor compliance, and maintains and publicizes a product certification database. Testing cycles will be ongoing. According to Reber, “More than two-dozen vendors submitted products for the first cycle of testing.”On July 18, those that meet 100% of the rigorous inspection requirements will be announced publicly and listed on CCHIT’s Web site.
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Ambulatory EHR:
Certification Criteria & Standards
Certification criteria. As of May 16, 2006, AHIC unanimously adopted all CCHIT criteria for certification of ambulatory EHRs. According to CCHIT Chairman Leavitt, “This first round of certification is a significant step in helping small and large practices decide what EHR product to choose.” Complete information and certification criteria can be found at www.cchit.org/work/criteria.htm.
CCHIT criteria fall into three specific “domains”:
- Functionality —for example, the documentation of prescriptions or other medication order detail for correct filling and administration.
- Interoperability —for example, the retrieval of immunization history from a registry.
- Security/reliability —for example, the protection of information access through password and other measures.
EHR standards. AHIC also approved 28 recommendations relating to software application standards for local, regional, and national health information networks. A public/private partnership group—the Health Information Technology Standards Panel—will develop standards for:
- Secure messaging between patients and clinicians, such as secure e-mail to allow a patient to receive a doctor’s advice outside a traditional office visit.
- Reporting results from laboratory testing, so lab results will travel with patients.
- Availability of electronic registration information to replace the medical clipboard.
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The Business Case for Paperless Medicine
Despite the national EHR push, a study of more than 3,300 medical group practices by the Medical Group Management Association (MGMA) found that just 14 percent of all medical group practices have invested in an EHR, pointing to an average purchase and implementation cost of $32,606 per full-time physician. Maintenance costs were an additional $1,200 per physician per month. Smaller practices had the highest per-physician implementation cost at $37,204, and the average cost for EHR implementation was about 25 percent more than initial vendor estimates. Lack of capital resources to invest in EHR was cited as the top barrier to adoption. Also, practices are not convinced EHRs will improve their performance or justify return on investment in terms of cost and quality.
“EHR certification criteria may actually accelerate the transition from paper to electronic records,” says Leavitt. “Although the initial investment remains significant, certified vendors will continue to upgrade products, delivering greater total value. Also, the greater volume of sales should drive down costs of products.
“A practice that waits to adopt EHR must consider an important ‘downside’: They need at least three months for EHR implementation, one year to collect data, and at least another year to put quality improvement mechanisms in place. The bottom line is that it will take them three years from the time they purchase [an EHR system] until they are ready to take full advantage of pay-for-performance reimbursement, and waiting until the last minute to go electronic could end up costing them money.”
Many experts believe that pay-for-performance systems may be the impetus needed to break through these barriers. Pay-for-performance would reward doctors for how they do on measures such as patient satisfaction, managing patients with chronic conditions like diabetes, or screening them for preventable problems like colon cancer.
“The funding [for these rewards] isn't fully there yet—and of course there are cultural barriers, legislative barriers, and privacy barriers too—but the national effort is attempting to overcome all of these barriers," says Leavitt, who strongly recommends that practices take steps now to implement eHealth.
To learn more about EHR implementation, services, and the first steps towards paperless, check out these past articles from For the Business of Medicine:
For additional information about CCHIT and EHR certification criteria for small and large group practices, visit www.cchit.org. To read more about the national eHealth initiative, see www.hhs.gov/healthit/ahiccharter.pdf.
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— Jo Ann Kairys, MPH, contributing editor