EMR Vendors on HITECH – Part Four of a Series

We asked several vendor executives a series of five questions related to the economic stimulus as it impacts electronic health records.

Much of the EHR-related compensation will come in the form of payment for improved outcomes. How do you expect that to be defined and what product capabilities will it require?


Allscripts – Glen Tullman, CEO

The government has aspired for some time to be able to implement comparative effectiveness analytics programs related to diagnosis and treatment protocols. The anticipation of a rapid EHR adoption curve over the next few years means there will be an exponentially larger pool of raw data available for these efforts, along with broad availability of the technology capable of collecting and transmitting that information. Chronic diseases such as diabetes, chronic obstructive pulmonary disease, hypertension, and others will likely continue to be a focus of this type of research. President Obama’s own personal interest in curing cancer will also likely lead to various manifestations of that disease being a focus of study.

Regarding product capabilities, improved outcomes will require that EHR products incorporate analytics functionality already available through Allscripts, with only the need to adjust the data pulled to match what CMS requires within the reporting process. We have for many years been looking past the point of mass EHR adoption towards a healthcare landscape in which quality care measures can be easily tracked and acted upon with the aid of our solutions. The government’s new focus on comparative effectiveness will only accelerate the timing of the transformation that we have long anticipated.

athenahealth – Jonathan Bush, CEO, President, and Chairman 

We define it as it is currently spelled out in the legislation that was signed – which we also believe will be expanded over time. We are aware of a HIT Policy Committee being formed to put more context to that and we welcome any new criteria that they will want prior to the start of the program and the subsequent years following. Again, anytime more data or the need to report complex data is required it further supports our network-based model. To think over the five year program that CMS won’t want the number of measures and other data sets captured and reported on increased is short sighted. They will and the vendors that are able to keep pace with that beyond just some software upgrade will be the best positioned to assist providers.

eClinicalWorks – Girish Kumar Navani, President

We think that it is fair to require that providers be compensated for use of the system and not merely for purchasing one. eClinicalWorks is already participating in projects like the Primary Care Information Project (PCIP) in New York where eClinicalWorks is used as a tool for quality improvement, and we are paid once physicians demonstrate use and report on outcomes. We have spent the better part of two years improving our solution for clinical decision support for chronic and preventative care. EMRs should be judged by how they automate the office without reliance on paper and as a tool for better patient outcomes.

Eclipsys – Tom Cooke, VP and GM of Eclipsys Practice Solutions

Eclipsys believes there is a large body of valuable outcomes-based measurement tools in use today that should be used to help identify appropriate levels of EHR-related compensation including:

• JCAHO core measures
• Never events
• Pay-for-Performance / PQRI
• Functional status surveys
• Healthcare Effectiveness Data and Information Set (HEDIS)
• RDRGs, APR-DRGs etc.

We also believe there needs to be new measures developed that track outcomes of chronically ill patients across multiple episodes of care.  Additionally, there should be statistically relevant ways at looking at health status of populations as well as individuals. Eclipsys continues to invest in software, content, monitoring tools, professional services methodologies and our client research to further these outcomes measurement tools.

eMDs – Michael Stearns MD, President and CEO

Pay-for-performance and care coordination programs like PQRI and the Patient Centered Medical Home will likely be modified to make better economic sense in both directions. Hopefully as these programs mature they will reward physicians who adhere to guidelines supported by evidence-based medicine. Regarding product capabilities, EHRs need to be able to capture information during documentation as “discreet” data that can be used for reporting. The systems also need clinical decision support tools that remind physicians of actions needed to be compliant with best practices. A mechanism that supports the automated updating of guideline information will also be central to the success of outcomes based compensation.

Greenway – Wyche “Tee” Green, President 

We see this following the lines of the Physicians Quality Reporting Initiative (PQRI) and outcomes criteria that has yet to be defined by the Secretary. I hope it will be in collaboration with entities such as the Agency for Healthcare Research & Quality (AHRQ) and the National Quality Foundation (NQF). As far as what the EHRs will have to do; it will be around the capabilities of reporting/exchanging information efficiently. Many will have to build central data exchanges to accomplish this on a mass scale. Fortunately for us, we have a platform in place called PrimeExchange that enables this data exchange.

MED3OOO – Jay Anders, M.D., Chief Medical Information Officer 

The greatest share of the incentive, in the beginning, will be paid for getting a system installed and fully operational. PQRI incentives based on demonstrated outcomes will start out as a smaller portion of the overall incentive and then grow. The government is moving very quickly to a population health management model with this administration. As CMS gathers more and more information about the ways physicians and hospitals deliver care, they will start to direct care to those physicians and hospitals that can demonstrate high quality through improved outcomes.

With healthcare costs consuming an ever-great portion of our GDP, CMS and other payers will move more and more towards a system in which costs are transparent and quality is rewarded. Payors, led by the government, will likely continue the trend toward “bundled” payments that reward providers for managing the total cost of an episode of care, and also facilitate the comparison of costs between providers.

The Congressional Budget Office predicts a $60 billion savings in healthcare costs by fully adopting EHR technology in the physician and hospital base. EHR product capabilities will be directed through the certification process to provide reporting data to support the quality improvement initiatives of CMS in high cost disease states such as diabetes. Ultimately, they will be a necessary part of data-driven pay-for-performance and pay-for-quality reimbursement systems.

Medsphere – Mike Doyle, CEO 

 
Again, Medsphere would hold up Midland Memorial Hospital as a prime example of improved outcomes. We’ve already mentioned three key areas (patient mortality, infection, unreconciled medications) where improved outcomes make a difference in patient lives, but there are numerous others. Almost all physicians at Midland are using OpenVista for CPOE, which ensures closed-loop medication administration and a much safer process. So, in noting that CPOE is part of Stage 4 in the HIMSS Analytics EMR Adoption Model, perhaps Stage 4 and the use of CPOE by a certain percentage of physicians would be a good standard. The elimination of never events, since government has already started down that path, is also a minimal standard to incorporate.

NextGen – Patrick Cline, President 

This also is a question that will likely be decided for us. But improved outcomes imply implementation of specific clinical processes, entry of patients and their data into the designed process, compliance tracking, and outcomes reporting. This will require a system to be robust enough, yet flexible enough, to configure required protocols, quality and outcomes measurements, and reporting tools without vendor-provided customizations. NextGen, by the way, already has many practices across the country that are tracking and reporting outcomes. In fact, many consider us to be on the forefront of providing the functionality that allows practices to receive significant incentive payments under such programs as the Physicians Quality Reporting Initiative (PQRI).

QuadraMed – Keith Hagen, President and CEO 

We expect improved outcomes to be largely based on the reporting mechanisms that exist today with The Joint Commission and CMS. It is important that reimbursement will be tied to these outcomes, not just quality reporting. We’ve seen this pay-for-performance regime coming for a while now and the ARRA will only accelerate it. We are well positioned to help QuadraMed clients both achieve and demonstrate improved outcomes. We have a strong solution set in place today that our clients can take advantage of: We are developing evidence-based order sets and advanced clinical decision support within QCPR. We have a market leading HIM solution set, including coding, compliance and abstracting. (This is an area most of our competition is relatively weak on and will become increasingly important in a pay for performance world.) Finally we have a web-based Joint Commission reporting and benchmarking tool (COPE – clinical outcomes practice evaluator) that clients are using today for quality reporting purposes.

Sage – Lindy Benton, Chief Operating Officer 

A significant part of this legislation is the ability to prove efficacy of different treatment options. Adhering to, learning from and contributing to evidence-based medicine and protocols is one of the main benefits of having a structured-documentation, single-database practice management and electronic health record system. Sage Intergy EHR uses MEDCIN structured nomenclature to create codified data during the encounter. The Sage Intergy EHR product, combined with the Sage Practice Analytics ad hoc reporting system to extract data from the system, perfectly positions Sage to comply with and provide employers, payers, CMS, NCQF and all other entities the required information. The physician also has analytical capabilities at their fingertips so they can repurpose information into knowledge for practice efficiency and improved quality of care.

SRSsoft – Evan Steele, CEO 

The incentives are intended to help bring about better outcomes. That won’t be accomplished by merely purchasing an EMR, regardless of who pays for it. Not only must the product be functionally competent, it must be a tool that is “usable” by physicians and other providers without impacting their productivity or getting in the way of providing care.

“Government” EMRs force physicians to input and collect data across the board. In contrast, hybrid EMRs identify the measures of interest up-front and limit the data collection appropriately, sparing physicians an overwhelming and distracting task. Once the government identifies the quality measures linked to the outcomes they want to evaluate, it should be up to EMR vendors to determine the most efficient way to collect this data. Why put the cart before the horse?

Improved outcomes are dependent upon several capabilities. First, ePrescribing will prevent medical errors due to drug-to-drug interactions, allergic reactions, duplicate prescribing, and illegibility of prescriptions, and it will help identify drug seekers. The data collected through ePrescribing will facilitate the measurement of the comparative effectiveness of drug treatments. The SRS hybrid EMR already includes a fully integrated, robust ePrescribing module.

“Government” EMRs typically require the building of structured “templates” as the means to collect exam data. This is time-consuming, costly, and inflexible for practices to do. SRS has developed a variety of options to facilitate efficient data collection to allow physicians to document exams the way they prefer. That is the advantage of the hybrid EMR. We also have the ability to incorporate whatever standards may emerge because of our Open Path™ architecture and user functions like “PowerTabs” and “Plug-Ins” that easily incorporate other external products and modules. We anticipate being able to respond quickly to the quality-measurement standards when they are published, as we have done with PQRI.

“Improved outcomes” will result from assisting the doctor in following pre-defined, evidenced-based treatment plans and protocols. We believe an EMR should be more than a repetitive, inflexible set of exam templates. It should be an adaptable tool set that helps busy physicians operate more efficiently and effectively. That means things like generating reminders and alerts. For example, the hybrid EMR can do the calculations and analysis on each patient and provide recommendations (e.g., prescribe beta blockers to all patients over 18 with history of CAD and MI).

News 3/24/09

CCHIT announces that it will speed up the process for its advanced technology certification programs, including clinical decision support, interoperability, quality, and security. Vendors will need to complete all these options for the 2009-2010 development cycle. The advanced clinical decision support and security components were not scheduled for completion until 2011. The new certification options will be finished by the time the HIT Policy and Standards Committees of HHS meet later this year, thus supporting ARRA’s certification requirements.

Speaking of CCHIT, new ambulatory certifications this month include iSuite Version 4 by MedAppz, SILK 4.2, and UroChart EMR by Intuitive Medical.

Physicians can now access the interactive online community QuantiaMD via their iPhones. QuantiaMD is already available for BlackBerry and Windows Mobile devices users. Question: when, exactly, does a physician access an online community? Most likely not while in the midst of seeing patients. Will clinicians really use a smartphone (instead of a PC) to review a clinical presentation or complete CME activities? What type of applications really make sense for clinician use on an iPhone or BlackBerry?

West Virginia’s optometrists and ophthalmologists are at odds over current legislation that would allow optometrists more authority to prescribe medications and perform minor surgeries. Ophthalmologists claim the legislation would put patients’ health at risk because optometrists are non-physicians with less training. Optometrists claim the current laws are antiquated and stand in the way of lower costs.

HIT leaders caution that providers must be educated on the new HITECH legislation incentives and potential penalties to avoid being hurt financially. Surely there are plenty of vendors and consultants begging for a chance to "educate."

Google will change its in-house employee clinic EHR to WebChart Enterprise EHR from Medical Informatics Engineering. The "minimally invasive EHR" will integrate with Google Health.

The program director for the Office of National Coordinator (ONCHIT) sees problems ahead for the Nationwide Health Information Network. Government systems follow a security standard called FISMA, while practice and hospital EMRs are designed to comply with HIPAA. The problem arises when patient information from the VA or DoD is sent to non-government hospitals and doctors. CCHIT is considering additional vendor certification for FISMA.

Former Missouri Congressman Richard Gephardt, now on the board of advisors of PHR vendor MyMedicalRecords (along fellow "formers" astronaut Buzz Aldrin and boxer Sugar Ray Leonard), will pitch the company’s products and try to get stimulus money to subsidize its PHR cost. He’ll be working the company’s booth at the HIMSS conference next Sunday.

This is a KLAS report, not a novel: The Rise of eClinicalWorks: Separating Fact from Fiction, which apparently lauds the company’s user product satisfaction and price-performance, but frets over growth-strapped implementation and support capabilities. You have to buy the report to learn more.

Consultants encourage physicians to use text-messaging to save staff time for such tasks as appointment reminders, lab calls, and follow-ups. Most web-based text applications can be free to set-up with average costs of $200 per month. Between estimated staff time savings of 50 minutes per day per provider, and the potential for increased revenue, texting could add $100,000 a year to the bottom line. Sounds a bit high, but then Mr. H and Inga aren’t big on text messages.

A Las Vegas internal medicine practice is charged with performing an estimated 15,000 unnecessary cholesterol tests on its patients over a three-year period. US attorney’s office claims the physicians overcharged Medicare by $130,000 for tests that were no more useful than performing a "mathematical calculation."  But, everyone knows that drawing blood is more fun that doing math.

In North Carolina, the number of doctors e-prescribing has doubled in the last quarter to over 2,000, according to BCBS of NC. The carrier offers a one-time $1,000 incentive to physicians who agree to submit e-Rxs to at least 20 patients. The state still has a ways to go to cover its 29,000 licensed practitioners.

Several SE Missouri physicians admit that the transition to electronic medical records was difficult, but worth it. A doctor in a three-physician family practice group says the EMR cost $100,000 three years ago, but saved $80,000 in overhead in the first year.

The government’s EHR initiatives appear to be boosting the stock performance of several HIT vendors. NextGen’s parent company Quality Systems, athenahealth, Cerner, and Allscripts-Misys have all outperformed the general market since President Obama was elected.

E-mail Inga.
E-mail Mr. HIStalk.

EMR Vendors on HITECH – Part Three of a Series

We asked several vendor executives a series of five questions related to the economic stimulus as it impacts electronic health records.

How is your company defining "meaningful use" of an EHR and how will ensure your customers can reach that level?

Allscripts – Glen Tullman, CEO

It is not our direct role to define “meaningful use” for the government. While the law has given us a sneak peek at what may be required, the new Secretary of HHS will further define the details. Accordingly, we are guiding our clients to understand that in order to collect the HITECH incentives, they will need to demonstrate that they are using a certified, ePrescribing-capable EHR that is connected for the exchange of relevant and appropriate personal health information (PHI) to the systems of other healthcare providers. Additionally, while we will not know for some time – likely not before 2010 – what the requirements will be for reporting on quality care measures (the third component of meaningful use), Allscripts is committed to ensuring that our products make it as simple as possible for our clients to comply with any directive that comes out of HHS at that point. Again, our best advice is for physicians to ensure that they are currently using or about to purchase a CCHIT-Certified Electronic Health Record and that the company they buy it from has the resources to invest in the future and is going to be around for years to come.

athenahealth – Jonathan Bush, CEO, President, and Chairman 

We define it as it is currently spelled out in the legislation that was signed – which we also believe will be expanded over time. We are aware of a HIT Policy Committee being formed to put more context to that and we welcome any new criteria that they will want prior to the start of the program and the subsequent years following. Again, anytime more data or the need to report complex data is required it further supports our network-based model.  To think over the five year program that CMS won’t want the number of measures and other data sets captured and reported on increased is short sighted. They will and the vendors that are able to keep pace with that beyond just some software upgrade will be the best positioned to assist providers.

eClinicalWorks – Girish Kumar Navani, President 

eClinicalWorks believes that “meaningful use” of an EMR involves making every aspect of the patient encounter electronic, which includes visit documentation, lab orders, e-prescribing and clinical decision support for preventative and chronic care. Meaningful use should enable physicians to eliminate reliance on paper charts and provide pertinent information at the point of care. Clinical decision support features help elevate the role of an EMR from passively collecting information to actively helping providers make informed decisions.

We have always invested heavily in our customers’ on-going training, providing around 20 free Webinars a week and multi-media educational materials. There is also an online users’ forum.

Eclipsys – Tom Cooke, VP and GM of Eclipsys Practice Solutions 

In our judgment, “meaningful use” can only be measured by how the software improves outcomes, whether these are clinical outcomes, satisfaction outcomes, efficiency outcomes, or financial outcomes. Today, the HCIT community has the opportunity to work together to develop industry guidelines for achieving “meaningful use,” which will then contribute to improved healthcare delivery and care.

We believe that one of the key guidelines should be proven interoperability between systems to enable clinicians to access complete patient information at any point throughout the healthcare continuum. Interoperability also will enable providers to quickly and cost-effectively deploy HIT solutions without ripping out legacy systems – an aspect that has become even more important in this economic downturn.

The “meaningful use” guidelines also should include support for a) the inclusion of evidence-based medicine and b) the sharing and implementation of industry best practices.

Eclipsys brings a wide variety of tools to our clients to help ensure “meaningful use” including:

• Demonstrated best practice rules and alerts
• Speed-to-value implementations
• Outcomes toolkits
• Evidenced-based order sets and documentation templates
• Social networking tools to allow client-to-client sharing of best practices, documentation templates, etc.

eMDs – Michael Stearns MD, President and CEO

The basic criteria outlined in HITECH include e-prescribing, interoperability and clinical reporting. We are hopeful this will be expanded to include clinical decision support and orders tracking. Fortunately our current level of functionality markedly exceeds these basic requirements. However, making sure our providers attain the meaningful use status, once it is defined by DHHS, will be a priority for our organization. We will be launching an extensive educational program for our clients. e-MDs currently offers practice optimization services and these will be modified to include meaningful use “certification.”

Greenway – Wyche "Tee" Green, President 

We are defining, just as the legislation states, that certified EHRs must have e-prescribing and interoperability capabilities, as well as outcomes and quality reporting. We feel that any company that has the most current CCHIT Certified products and is committed to advancing their platform along the CCHIT 09 plan is well-positioned to ensure their customers are afforded a solution that can be “meaningfully used.” Every company must stay nimble, flexible and adaptive to change in order to be successful in this area.

MED3OOO – Jay Anders, M.D., Chief Medical Information Officer 

This is a tough area to address specifically, as ONCHIT has great latitude in setting this standard. I believe that physicians and groups will be required to demonstrate meaningful use, either by reporting PQRI from the EHR or by applying a yet-to-be-determined code that their visits were documented within the system when they are sent to CMS for processing. Practices will also need to demonstrate that they are using EHR for the great majority, if not all, of their patients—75% use in this area has been alluded to in other parts of the law and will probably be adopted in the regulations. Given the latitude here, we are working with all our clients to fully adopt all the functionality of the EHR so that they will meet whatever criteria the regulations require.

Looking beyond the specifics of the HITECH Act into the motivations behind it, the “take home” point here is that EHRs are expected to do much more than automate current physician practices. Meaningful use of EHRs will enhance the quality of patient care, promote the portability of health care, create efficiencies in the delivery of healthcare services, and ultimately lower the aggregate cost of care. These are the higher standards which we’re helping our clients achieve.

Medsphere – Mike Doyle, CEO 

Medsphere defines “meaningful use” of an EHR as Clinical Transformation. Is the EHR being used to improve care in statistically measureable ways? OpenVista was used to do exactly that at Midland Memorial Hospital, reducing patient mortality, infection rates, and unreconciled medications. An EHR needs to provide real-time physician access to relevant patient information from various points of care. It also must improve clinical outcomes, as OpenVista has.

NextGen – Patrick Cline, President 

Again, a vendor perhaps should not be providing such a definition as it would be hard to do so without it being seen as self-serving. Let’s just say that whatever the definition is, we feel comfortable that practices that have installed or will install NextGen under this program will be able to meet the requirements – both in terms of functionality and reporting – that will be instituted to verify "meaningful use." We do know that a portion of the requirement for meaningful use will be e-prescribing, connection to a health data exchange and submission of clinical quality data. Our current clients and those considering NextGen can take comfort in the fact that all three capabilities have been practically demonstrated in client sites, using the currently available NextGen 2008 CCHIT certified solutions.

QuadraMed – Keith Hagen, President and CEO

 
According to the HIMSS Analytics ‘EMR Adoption Model’ there is a major drop-off between Stage 3 (basically nursing documentation) and Stage 4 (CPOE with embedded clinical decision support). According to the 2008 survey, 36% of hospitals have attained Stage 3 but only 2.5% have attained Stage 4. Most of QuadraMed’s clients have achieved Stage 5 (closed loop medication administration), which is an area of strength for our QCPR product. Given this drop off we think the incentives being put into place today should be aimed at moving hospitals from Stage 3 to Stages 4 and 5. We will be focusing on moving our clients to QCPR with its integrated medication management functionality. We are confident that by implementing QCPR our clients will attain ‘meaningful use’. 

Sage – Lindy Benton, Chief Operating Officer 

While we wouldn’t be so presumptuous as to define the term, there are probably some assumptions that can be made. E-prescribing, the capture of discrete data during the encounter, and some level of interoperability will likely be required. Additionally, to meet the goals for comparative effectiveness research, some level of outcomes reporting will be involved.

One of the goals of our new services organization is to help customers – existing and those to come – meet the “meaningful use” standard once it is defined.

SRSsoft – Evan Steele, CEO 

We define “meaningful use” from the physicians’ perspective. “Meaningful use” of an EMR is achieved when that EMR successfully enables a physician to accomplish his/her goals for quality of care, cost-effectiveness, and outcomes measurement—and it is more likely to be achieved by technology that does not compromise productivity or practice style.

The government’s “meaningful use” requirements pose a significant hurdle to physicians who are tempted by the $44,000 incentives. How can physicians become meaningful users of systems that have been shown to reduce their productivity? Even the government, through the Congressional Budget Office, has said that EMRs may cause “financial harm” to office-based physicians.

There are 4 landmark studies that have demonstrated that “government” EMRs (traditional, CCHIT-style EMRs) impose hardship on physicians (http://www.srssoft.com/landmarkstudies.php). Not a single landmark study exists that concludes otherwise. If you can find one, please post it as a comment at the bottom of this interview.

With this backdrop, it’s easy to compare the stimulus plan to the government offering $44,000 of credits over a 5 year period to purchase a “government designed” car that has a maximum speed of 48 miles per hour. To get the incentives, the driver must first pay for the entire car up-front and then the driver must prove “meaningful use” of the car to a government agency via various reporting mechanisms. If he stops using the government car in a meaningful manner because he is always running late or he finds that 48 mph doesn’t suit the way he drives, he is stuck with the entire cost of the car. If it were known that over 50% of the time, drivers who purchase government cars abandon those cars and lose the entire investment, who in their right mind would buy a government car?

The same problem exists with government EMR. Everyone wants the EMR incentives, but the realities of a fast-paced, busy medical practice will cause physicians to abandon the EMR systems just as they have been doing en masse without the incentives. The incentives will only accelerate the demise of traditional point-and-click EMR systems as physicians with less IT proficiency and a lower level of IT support attempt to use the very same systems that have failed among the deep-pocketed, more technically savvy early adopters.

Thankfully for doctors, government EMR adoption is 100% voluntary and, over the next 9 years, the incentives are relatively small as a percentage of their total income. Therefore, doctors are free to purchase the digital solution that best meets their practices needs—one that incorporates the voice of the physician rather than the voice of government.

If an EMR can be built according to government specifications that we feel physicians can “meaningfully use” without being slowed down, SRS will develop such a product. If sometime late in the next decade CMS requires the use of an EMR, then SRS stands ready to provide its clients with the software they need. In the meantime, we keep listening to what our clients want and to provide a hybrid EMR that works wonders for their practices.

EMR Vendors on HITECH – Part Two of a Series

We asked several vendor executives a series of five questions related to the economic stimulus as it impacts electronic health records.

Providers will be required to implement “certified” software to participate. Who should perform the certification and what criteria should they use?

Allscripts – Glen Tullman, CEO

We believe the Certification Commission for Healthcare Information Technology (CCHIT) is very well positioned to perform the certification of EHRs. Allscripts has been a strong supporter of CCHIT – one of the industry’s primary product certification bodies – since its inception.  We are pleased that Congress appears to recognize the good work CCHIT has done through its certification process and that HHS will likely base many of its go-forward standards on that work. Today, all of the products in our EHR portfolio have current CCHIT certification, and we intend to ensure that every one of our clients is in a position to participate in the new Stimulus incentives that will become available starting in 2011.

Regarding criteria, we believe CCHIT is on the right track with its Roadmap for Expansion of Health IT Certification. We support CCHIT’s plans to include advanced interoperability, advanced quality, advanced security and advanced clinical decision support in their 2010 and 2011 certification programs. Doing so will contribute to ensuring that the widespread adoption of Electronic Health Records envisioned by President Obama results in true transformation of our healthcare system. It’s critical that physicians use EHRs that reach beyond their own practices in an interoperable fashion rather than becoming simply another “software silo.” To get there, we need to ensure that physicians and patients alike feel confident that their information will be secure. We need to ensure that certified EHRs are capable of capturing and analyzing information needed for participation in pay-for-quality programs. And we need to ensure that physicians receive real-time, accurate clinical decision support to harness the power of information.

With a certification process that measures all four of these areas – interoperability, security, quality and advanced decision support – we have a real chance to truly improve the quality and lower the cost of providing patient care in the US today.

athenahealth – Jonathan Bush, CEO, President, and Chairman 

As we all know CCHIT handles this process, and we are currently in the midst of certifying for 2008 and will look to certify athenaClinicals for every single year moving forward. I am sure more and more standards and privacy entities will appear in years to come and athenahealth will incorporate whatever measures they require into our national network just the same as we do today . There will be no cumbersome version “whatever” launch and subsequent failure for athenahealth as we see with traditional software players. We release 6-8 major new versions of athenaNet a year across our entire national base over night. We also update athenaNet daily with new payor and clinical rules, security, and privacy measure etc. Today we have over 40 million various scenarios that require our proprietary rules engine in athenaNet to fire in order to guide providers away from making billing or clinical documentation errors that would lead to a poor outcome – unpaid claim or incomplete patient record. To this end, we have a website http://www.athenahealth.com/campaign/hitech/index.php , as do most HCIT vendors on the HITECH Act and issues around certified systems. However, we tried to communicate the realities of this program and attempt to give providers a moment of pause before they select the very same stagnant software systems that have proven not be adopted and utilized for many years. Certification of certain software functionally does not directly correlate with ROI or adoption. We believe providers are getting savvier to the fact they need much more flexible clinical systems that will be able to change with an evolving healthcare system and not wait hat in hand for the latest and great upgrade. I think we even saw some interesting research from Avalere Health researchers on this issue that indicated a solo or small group physician practice will spend an estimated $124,000 over the five year period of 2011-2015 to adopt and maintain a traditional EHR, and could receive up to $44,000 in federal incentive payments.  The resulting financial deficit would be $70,000, or an average of $14,000 a year. The value has to come from both vendor and the incentive – software functionality is only a small part of this.

eClinicalWorks – Girish Kumar Navani, President 

Interoperability is a key objective for eClinicalWorks. Standards should focus on sharing patient records in a way that is private and secure. It is also important that technology promotes patient care, preventative measures and disease management. We would like to see standards in place that support these aspects. Whatever standards the government decides on, we are confident that we will meet them.

Eclipsys has been, and remains, a supporter of CCHIT as the proverbial Underwriters Laboratory (UL) for HCIT. We believe it is in everyone’s interest for the industry to police itself through this independent “Good Housekeeping Seal of Approval” process. Eclipsys believes that the roadmap for functionality and interoperability being laid out by CCHIT is reasonable and appropriate to create standards of certification.

eMDs – Michael Stearns MD, President and CEO

Our EHR has been certified by CCHIT in 2006, 2007 and 2008, including the child health and cardiovascular specialty certifications offered in 2008. Regardless of what direction the DHHS secretary and national coordinator decide to take, we fully commit to being compliant with any and all EHR certification requirements.

To date, CCHIT has provided the most effective and thorough certification process. The industry as a whole has invested millions into certification, interoperability, privacy and security with tremendous achievements in the last three years. Products that are currently certified with 08 CCHIT criteria have a high level of functionality that deliver long-term and interoperable solutions. CCHIT is currently the only recognized certification body (RCB) by the Secretary and by starting over; we will take considerable steps back.

The bill has language that puts the oversight of the certification process in the hands of ONCHIT. The logical assumption is that CCHIT will continue as the organization that will recommend criteria to the office of the National Coordinator, with input from the new national HIT policy and standards committees. Overall, CCHIT has done a good job in setting criteria that advance EHR functionality. I believe they should continue in this role, with oversight from ONCHIT.

We can’t say exactly who should perform the certification, and we don’t really want to. That may not be much of an issue. What the certification focuses on and requires is more relevant. Now, might the requirements demand that government oversee or take some roll in the process? Yes, they might.

The assumption seems to be that CCHIT will be the certifying body, though the organization isn’t mentioned in the legislation. Historically, CCHIT certification has not incorporated considerations such as interoperability, transparency, or affordability, which were alluded to by Congress. Maybe the requirements that come out in April will. Medsphere thinks certification must incorporate these elements. Perhaps government oversight will be required to ensure they are addressed.

What criteria should they use?

• Proven (evidence-based) to improve clinical outcomes: Medsphere’s OpenVista EHR is built on VistA, the proven and popular VA EMR system field-tested by the U.S. Department of Veterans Affairs (VA) for two decades in more than 1,300 sites of care, including 160 medical centers and 850 clinics. VistA was designed specifically for the outcomes-oriented management of patients with chronic disease, which sets it apart from most health information systems. The changes resulting from VistA at the VA are considered the largest case study ever of objectively improving care. Peer-reviewed research has documented the VA’s higher compliance with performance standards, unparalleled patient safety improvements, and better overall health outcomes than private-sector organizations resulting from its use of VistA.
• Affordable / Cost-effective: Medsphere’s OpenVista EHR leverages the multi-billion dollar public investment in the comprehensive and highly-acclaimed VistA EHR. In commercializing an already valuable tool, Medsphere has transformed VistA into OpenVista, a feature-rich EHR designed to meet the needs of acute, ambulatory, and long-term care environments as well as multi-facility, multi-specialty healthcare organizations.
• An innovative pay-as-you-go subscription pricing model enabled by open source technology incorporates no mandatory upfront implementation costs, a departure from traditional “vendor lock” solutions. Medsphere creates ongoing value via product upgrades and application support included in every subscription, helping customers get the most from their solution now and for years to come. Plus, the most a hospital is eligible for under the federal legislation is $11 million, which will easily cover OpenVista implementation. Ask Cerner or Epic if they want to do an implementation for that price.
• Interoperable: OpenVista works with existing hardware and software, thus preserving legacy IT investments. When deployed across the enterprise, the integrated platform delivers superior time-to-value and time-to-benefit. The interoperability incorporated into OpenVista also enables health information (HIE) exchange and broader coordination of patient data where other solutions simply don’t. We clearly seem to moving toward more information flowing to hospitals and clinics around the county. How is that possible if patient records are locked up in proprietary systems that won’t play nice?
• Fosters collaboration: How would healthcare progress if advances in medicine were retained by individual hospitals or research facilities? The same question is relevant with health IT. When a hospital or university develops an effective application or template, there is something unconscionable about not sharing it with other healthcare providers, particularly if it can directly and positively impact patient care. As an Open Source solution, OpenVista and our Healthcare Open Source Ecosystem encourage people to get under the hood and create. There are a hundred ways to approach a task, and only through a diversity of opinion unfettered by corporate orthodoxy can we find the best one.

As a vendor, it may not be appropriate for us to comment on who should perform the certification. But let me be clear that we support the need for the body to be well respected by all participants – including physicians. As far as the criteria needed, it probably makes sense to look towards the CCHIT 2008/2009 criteria, at least as a starting point. Various stakeholders can certainly be included in the process to make sure that all sectors are represented. It is likely that their additions, expansions, or even deletions and corrections to the CCHIT criteria should help the process gain widespread acceptance.

It makes sense that CCHIT will be the certifying body. The group has done a good job of establishing “harmony,” credibility and legitimacy among vendors, payers, providers and other 3rd parties. Additionally, there is synergy with the CMS demonstration programs since the new incentive program leveraged the CCHIT certification criteria.

However, the legislation leaves specifics unfulfilled. We will be closely monitoring developments to ensure we meet all certification requirements.

Certification requirements should be determined by a group led by the end users—that is, the busy, practicing physicians who will be using the software. The software they would structure would be easy to use, increase their productivity rather than ask them to be data entry clerks, generate reports based on the outcome measures they identify, and streamline practice workflows.

In contrast, the starting point for government EMR standards under the Stimulus Plan will likely be CCHIT. It is unfortunate that the 21-member CCHIT commission lacks significant representation by front-line, private-practice physicians. There is nothing in the certification criteria that requires that features be usable and convenient for the doctor. Of the 477 feature-focused CCHIT certification criteria for 2008, not one addresses usability. For example, it can take a doctor 20 productivity-sapping clicks to accomplish a task with a certified feature, but as long as it produces the desired result, that feature will pass certification with flying colors.

Compounding the frustration, the HITECH legislation creates a newly formed HIT Policy Committee charged with setting overall policy and overseeing the distribution of the Stimulus Plan funds. Unfortunately for front-line physicians, the committee will consist of a group of 20 politically appointed individuals with only one physician representative. This does not bode well for the development of usability-based criteria that physicians will find adoptable.

Instead of focusing on features alone, EMR developers should focus their energy and R&D budgets on producing elegant, streamlined, and efficient products that are highly usable. This has always been, and remains, the focus at SRS. Alternatives to CCHIT-type EMRs, such as hybrid EMRs, should be evaluated for their ability to boost the EMR-adoption rate.

EMR Vendor Executives on HITECH – Part One of a Series

We asked several vendor executives a series of five questions related to the economic stimulus as it impacts electronic health records.

What changes will your company or area make, both for the short and long term, in preparation for HITECH legislation?

Allscripts – Glen Tullman, CEO

Within hours of President Obama’s signing of the American Recovery and Reinvestment Act, Allscripts began a process of educating the market on the HITECH elements of the Act. Our outreach included a series of webcasts (such as one this week with Glen Tullman and Newt Gingrich), a new website (www.allscripts.com/thetimeisNOW), a white paper, and a variety of other tools that help physicians better understand the implication of the new programs on their practice. Additionally, we will soon be introducing innovative new pricing oriented around the Stimulus. And you can expect to see major new Allscripts announcements related to the Stimulus very soon as we ramp up our national program to help physicians take advantage of the HITECH incentives to enter the Electronic Healthcare Highway.

Internally, Allscripts continues to hire new people as the need arises, with every expectation that the Stimulus will drive significant new hiring down the road. From a development standpoint, we expect to accelerate our efforts around interoperability and connectivity, ensuring our clients are ready to connect.

Overall, it’s important to keep in mind that there are already compelling reasons to start using an EHR today, with very significant financial incentives from the Centers for Medicare and Medicaid Services (CMS) for electronic prescribing as well as the CMS Physician Quality Reporting Initiative (PQRI) and other pay-for-quality programs from many local health plans. These existing financial incentives enable physician practices to start generating new revenue streams today, even before the HITECH incentives kick in – good news in these difficult economic times.

athenahealth – Jonathan Bush, CEO, President, and Chairman

We have already been in the process of developing an extensive clinical content team much like our payor rules team that will update, qualify, and build various clinical quality measures directly into our national EHR platform allowing all of our clients using athenaClinicals to more easily participate in whatever pay-for-reporting program is developed for the HITECH Act but also as more commercial insurers launch P4P programs. athenahealth’s analyst teams already today help practices capture and report for these programs unlike traditional software, whether it’s client server or hosted, the burden is on the end user to use various functionality in an attempt to participate. We believe this is why so many medical providers had frustration attempting to report out for PQRI using software-only systems. In contrast, 100% of athenahealth clients that participated in PQRI received their bonuses. The government’s incentive program will only further the need to innovate network-based services that medical groups will need to leverage moving forward.

eClinicalWorks – Girish Kumar Navani, President

 eClinicalWorks is holding regular meetings with the department heads to forecast the staffing needs of each department. New employees were starting even before the stimulus, but we are hiring more aggressively now. We are also looking for ways to streamline processes to ensure that we are running as efficiently as possible.

Eclipsys – Tom Cooke, VP and GM of Eclipsys Practice Solutions

Eclipsys, the Outcomes Company, is excited about new sources of funds coming into HCIT from the Federal Government, and believes that it will stimulate even greater market demand for Eclipsys solutions. Our mission to maximize client return on investment while delivering improved patient outcomes mirrors the goals expressed by the administration and will not fundamentally change our corporate strategies. As such, we continue to assist our clients with the following:

• Automate as many endpoints with Eclipsys solutions as practical, and as quickly as possible. From the ICU to the family practice, from the ED to the laboratory shop floor, Eclipsys provides world class automation, extraordinarily high adoption rates, and measurably superior outcomes for our clients.
• Design interoperability into every portion of our solution portfolio. While some of our competitors strong arm providers to automate every community endpoint with their solutions, we recognize that widespread IT adoption means supporting a realistic, heterogeneous environment. Each of our solutions has a multiplicity of ways to interoperate with other solutions and technologies, and we have introduced our Health Information Exchange technologies to provide this community interoperability at the lowest cost, and highest degree of effectiveness possible.
• Work seamlessly with the interoperating community of stakeholders to monitor performance, identify and eliminate waste and duplication, and improve financial and operational performance through revenue optimization and cost reduction.
• Transform practice at the point of care by integrating evidence-based medicine into daily clinical processes through knowledge-based and decision support solutions.
• Introduce and monitor performance of evidence-based medicine throughout the community through the instantiation of protocols and pathways published in peer reviewed literature.
• Amass, normalize, and research clinical, operational, and financial data in order to allow our clients to further contribute toward the evidence-based medicine available.

eMDs – Michael Stearns MD, President and CEO

e-MDs is preparing for very significant growth in all areas of the company, including training, support and ASP hosting services. We have committed significant resources towards educational efforts related to HITECH and the other HIT related provisions in ARRA. This company has accelerated efforts to strengthen alliances and partnerships with other organizations, academic centers and government agencies. We are also working directly with communities interested in developing HIT regional extension centers.

Greenway – Wyche “Tee” Green, President

In the short term, we are paying close attention to any developments that will impact both our customers and our company, such as the definition of “meaningful use” and the final certification process, which we hope will align with CCHIT as much progress has been made during the last three years. We recognize that Greenway will continue to experience rapid growth and that’s something our team is prepared for.

MED3OOO – Jay Anders, M.D., Chief Medical Information Officer

MED3OOO is well positioned to help our clients, both physicians and hospitals, to maximize their potential with the stimulus bill. In the short term, we are working with current clients to help them analyze their qualification status and to make sure they meet the meaningful adoption criteria to qualify them for the incentives. In the long term, we believe there will be a “gold rush” of prospects looking for systems to be quickly implemented and meaningfully adopted.

Remember that the greatest incentives are offered to physicians who implement EHRs in (or before) 2010. Typical in-house EHR implementations can take six-to-nine months, with additional time before and after spent in preparation, negotiations, training, and implementation. That doesn’t give physicians much time to get ready. MED3OOO’s Software as a Service (SaaS) implementation and InteGreat EHR’s browser-based deployment allow our customers to be “live” on their EHR in less than half the time required by traditional EHR product installations. Also, through the SaaS service model, monthly service fees can be paid entirely using the HITECH incentive payments.

Lastly, it’s important to note that the legislation wisely rewards, not the installation of EHR technology, but the effective use of that technology. MED3OOO has its roots in practice operations, and we’ve used this expertise to design and implement technology in ways that physicians can use to improve outcomes for their practices and their patients. Our InteGreat EHR, for example, gets high marks for its “intuitive” interface and the ease with which it can be effectively installed and utilized. We believe that a collaborative approach with physician practices, and a grounding in the operational requirements of those practices, will be essential factors in the successful implementation of EHR systems.

Medsphere – Mike Doyle, CEO

Like many health IT providers, Medsphere is preparing intently for the impact of federal healthcare IT legislation. We are anticipating some sort of certification requirement and developing accordingly, and we recently finalized a services partnership with maxIT and conducted the first session of Medsphere University to get them up to speed with OpenVista and the Clinical Transformation it enables.

We’re also preparing for the legislation by tailoring a solution that fits within the parameters (time and money) of the federal program. Medsphere is better prepared than many other health IT companies to enable full funding for hospitals when money becomes available. We’ve implemented OpenVista in anywhere from 5 to 18 months, depending on the specifics of the implementing hospital, and we’ve developed a process that incorporates a great deal of flexibility. Medsphere has demonstrated that we can implement an interoperable solution incorporating all necessary clinical functionality for roughly ½ the cost and in 1/3 the time of other solutions. We can implement a system for the amount of money available to hospitals. A lot of other healthcare IT provides can’t say the same.

NextGen – Patrick Cline, President

There are several ways to answer this question. First, with respect to the legislation, its interpretation and the surrounding process: Things are still evolving and, at this point, information is still incomplete. To help keep our customers current, we have developed a microsite, http://www.nextgen.com/stimulus/ that presents our current understanding of the legislation, regularly updated pertinent information and a set of Frequently Asked Questions (FAQs). We have also started a series of educational webinars discussing the legislation, as well as services we are offering providers who are using or have decided to select NextGen solutions.

With respect to the long term, we think we’re well positioned product-wise, but we continue to work on our ability to scale the company and train the new customers that we hope will come at an increased rate. We intend to open additional training centers, enhance our computer-based training programs and make our software even easier to use.

QuadraMed – Keith Hagen, President and CEO

As a result of the ARRA, QuadraMed is now extremely focused on having our enterprise clinical product, QCPR, meet the to-be-determined NIST certification criteria. In lieu of these criteria being formally defined, we are using the CCHIT criteria as a target. We feel we meet the majority of these criteria today but are fast-tracking other development projects around advanced clinical decision support and CDA/CCD support. Additionally we are working on extending our integrated medication management functionality to support areas like e prescribing. Our plan is to be in a position to submit QCPR for certification by Spring 2010.

Sage – Lindy Benton, Chief Operating Officer

In the short term, we are investing in service infrastructure, employee education and reevaluating processes to become more efficient and proactively prepared to respond to the increased demand for solutions and service. Additionally, over the past two years, we’ve invested in technologies that reduce implementation efforts for both the customer and Sage – so we can quickly meet market demand without large increases in human capital.

We’re also optimizing our portfolio of intellectual property and services – ensuring we offer the right value to our customers. For example, we are launching a Center for Knowledge Excellence organization that will provide optimization and education services. These services will wrap around our products and help practices become more efficient and achieve specific clinical goals and outcomes. We want our customers to leverage the products to create maximum value and, specifically, to assist practices in achieving the “meaningful use” standard.

Even with these efforts, it is expected that we will most likely need to increase our human capital investment over the longer term.

SRSsoft – Evan Steele, CEO

Why should we change? We challenge ourselves with this question every day. Why would we abandon our focus on efficiency, usability, and 100% successful implementations? We have yet to be given a compelling case to do so, even with all the incentives being dangled before practices. In fact, why does the industry need incentives to implement technology at all? If traditional EMR offered such great benefits to patients, physicians, and the medical ecosystem in general, why has adoption been so slow and been marked by so many failures? Will incentives provided by the government for these same EMRs result in a different outcome?

The hybrid EMR has significant advantages over what we are calling the “government” EMR in terms of speed, ease of use, and adoptability. It successfully provides ePrescribing and PQRI capabilities, robust reporting, and data management functionality, and it also enhances practice workflow and physician productivity. SRS will continue to listen to exactly what our physicians want and to develop features that make them more efficient and enhance their ability to deliver high-quality patient care.

We refuse to pour resources into developing overly complex products when we know that physicians do not find these types of products usable. Sadly, this is the path that CCHIT has followed, as a reading of the CCHIT criteria reveals. At SRS, we have the voice of the physician built into our software, which has led to a level of user satisfaction that is the highest in the industry by a wide margin, as validated by KLAS.