Practice Fusion Blog

An Open Letter to ONCHIT Chief David Blumenthal

In their roles as HIT consultants, bloggers and policy analysts, David Kibbe and Brian Klepper have helped shape the national debate concerning issues of great importance to Practice Fusion. They've pushed forward our collective thinking, for example, about the term, "meaningful use of EHRs," and they've raised legitimate concerns about the role of CCHIT in the EHR certification process.

Now Kibbe and Klepper have raised concerns about another area--the process by which HITECH legislation becomes translated into implementable public policy.

In particular, they have questioned the approach being used by one of ONCHIT's 2 main criteria-setting committees.

After explaining their concerns to us, Kibbe and Klepper asked whether we would sign a petition to ONCHIT Chief David Blumenthal, in which they voiced their concerns. We said yes, as did some rather formidable players in the HIT space.

Here is a copy of their letter, along with a list of the signees:
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Dear Dr. Blumenthal:

We would like to request that the same exemplary openness, transparency, and support for innovation set by the HIT Policy Committee is followed by the HIT Standards Committee. We ask that the HIT Standards Committee support an evidence-based approach and open discourse about health IT standards and ensure again, as has been done so well thus far, that the results support innovators easily adding value to our health care system.

We applaud the work of the HIT Policy Committee to date. Just as it has been in the nation's best interests to re-open the EHR technology certification discussion in light of NIST's expertise and an international Conformity Assessment framework, it is in its interests to re-open the health IT standards discussion in light of recent experiences and market activity with health data exchange here and abroad.

While CCHIT and HITSP have accomplished some good work, both have been overly influenced by the same small group of special interests, and have created at least the appearance of conflicts of interest. Representatives from the legacy vendors, traditional health IT interests, and large health system enterprises have dominated the Health Information Technology Standards Panel (HITSP). A good example is HITSP’s June 2008 reorganization of its technical committees. Seventeen co-directors were announced for these six committees. Of the fourteen non-governmental co-directors, eight were current or recent employees of just three large pre-Internet enterprise vendors; three were from large vertically integrated delivery systems; and two were from large insurers. There were no co-chairs from emergent or potentially disruptive/innovative technology companies, or those with open source experience. No one representing Google, Apple, or Microsoft, for example. There were no practicing physicians and no patient advocates.

We are concerned because we hear from some of the people who are experienced in building successful standards in IT that the legacy standards largely promulgated by HITSP thus far will be a massive impediment to smaller more nimble innovators. It is very important that health IT standards not “lock out” the experience of other industries - e.g., financial services, e-commerce, and online publishing - which have evolved broad and deep Web-based infrastructures and marketplaces in which proprietary software and hardware are no longer prominent. In this case, it is vitally important to include the voices of the innovators in health care IT and data exchange, such as Microsoft and Google, Apple's iPhone, MinuteClinic and SureScripts, and their many partners.

At the very least, an evidence-based approach to health IT standards selection would consist of hearings to systematically review the best practices and lessons from health data exchange, particularly with respect to the uses of XML as a format and language for secure and interoperable transfers of summary health data like those contemplated as requirements under Meaningful Use by EHR technologies. The information distilled from this exercise could be placed alongside HITSP's conceptual constructs and enterprise use-cases. (In some instances, HITSP has recommended untested and unproven "standards" that experts have already questioned in terms of their suitability for real world implementation. Certainly, if ONC is considering translating these into national policy, they should be subject to full review in a public forum, followed by adequate testing.)

An evidence-based approach to standards selection would bring the innovators with actual experience to the discussion. An open forum would allow this testimony to help ONC's staff and the Committee members get a much better idea of what works, and what doesn't. This letter's signers and, we believe, others with deep field experience, would welcome the opportunity to testify and share their knowledge.

We understand ONC's and the Standards Committees' time pressures. On the other hand, an approach that ignores the evidence from the marketplace and practitioners outside health IT's "old guard," is simply a means of hurrying to failure, not marching to success. This is why we believe it is urgent that the discussion regarding health IT standards be re-opened immediately.

Thank you for your consideration.

Respectfully,

David C. Kibbe, MD MBA and Brian Klepper, PhD

Co-signatories:
Steve Adams, CEO, RMDNetworks, Inc.
Richard Benoit, Dossia
Edmund Billings, MD, CMO and EVP, Product Development, Medsphere
Warren Brennan, CEO, SMA Informatics, Richmond
Bill Crounse, M.D. Senior Director, Worldwide Health, Microsoft Corporation
"e-Patient Dave" deBronkart, Patient, Co-Chair, Society for Participatory Medicine
Michael Fleming, MD, FAAFP Chief Medical Officer Amedisys, Inc.
Sarah Greene, Managing Editor, Journal of Participatory Medicine
Alan Greene, MD, co-founder, DrGreene.com and President, Society for Participatory Medicine
Adrian Gropper MD, Chief Science Officer, MedCommons
James Allen Heywood, Chairman and Co-Founder, PatientsLikeMe
Stasia Kahn, MD, Founder, Physicians for Connectivity and General Internist, Fox Prarie Medical Group
Vince Kuraitis, Prinicpal, Better Health Technologies, LLC
Glenn Laffel, MD, PhD, Sr. VP Clinical Affairs Practice Fusion
Randall Oates, MD, President, SOAPware, Inc.
Martin Pellinat, CEO, VisionTree Software, Inc.
Rick Peters MD, President + CEO, Rocket Technology Labs, Inc.
Jane Sarasohn-Kahn, Principal, Think Health, Philadelphia
Tom Schwieterman, MD, Director of Research and Development, Midmark Corporation
Ravi Sharma, CEO, 4Medica
Rahul D. Singal MD, President and CEO, WorldDoc Inc.
Carl Taylor, Director, Center for Strategic Health Innovation
Mary Eleanor Wickersham, Director of Health Policy, GA Governor's Office, Atlanta

cc: Jonathan Perlin, MD, John Halamka, MD, John Glaser, Paul Egerman

HITECH Boosts Health IT Stocks

After a frightening free-fall in Q4, 2008 most domestic stock indices regained their footing in the first 6 months of this year. The Standard & Poor's 500 index was up a modest 2% for the period, for example.

Health information technology stocks blew past this performance however, as the sector gained 30% on speculation that HITECH funding would soon lead to a bonanza for the sector.

Allscripts-Misys stock was trading at $15.86 at the end of Q2, 2009, up from $9.92 at the beginning of the year.  Similarly, Cerner’s stock was trading 38% higher than on January 1.

HITECH, a part of the American Recovery and Reinvestment Act of 2009, mandates that at least $20 billion to be paid-out via Medicare bonus incentives to providers who demonstrate “meaningful use” of certified EHRs beginning in 2011.

Although prospects for the sector continue to look favorable, Christopher McCord, a principal of Healthcare Growth Partners voiced some concern. “Meaningful use still needs to be better understood,” he told Modern Healthcare.

In this regard, ONCHIT’s HIT Policy Committee remains on track to release final definitions for the key concept by this fall.

Also later this year or by Q1 10 the latest, ONCHIT will designate EHR certifying bodies. Currently, CCHIT has a monopoly on EHR certification but no one—including CCHIT itself—expects this to continue. 

As for health care providers themselves, they will likely continue to push for implementation delays on certain aspects of the “meaningful use” guidelines, but they’re not going to turn their backs altogether on the $20 billion windfall.

Glenn Laffel MD, PhD, Sr. VP Clinical Affairs

Is “cloud computing” right for health IT?

The announcement of Salesforce.com investing and coordinating development efforts with Practice Fusion has brought talk of “cloud computing” to the fore. Salesforce has been known as a leader in cloud computing, and moving healthcare IT to that “cloud” has raised questions by a number of observers. What, exactly, is “cloud computing?” Is it appropriate for health IT? What are the security issues and risks?

“Cloud computing” is a term described as a style of computing in which on-demand resources are provided as a service over the Internet. Software-as-a-service (SaaS) is a type of cloud computing, where users do not need to install or maintain any software themselves – simple Internet access and a browser are all that is needed.  Users do not need to have knowledge of, expertise in, or control over the technology infrastructure in the “cloud” that supports them – the Internet site (e.g. Practice Fusion) provides a unified dashboard to the user, and works out the technical issues of presenting that data in the background.

Is this approach appropriate to health data? One of the greatest advantages of a “cloud” approach is that the network, server and security headaches that exist for locally-installed, legacy client/server systems is eliminated. Cost and poor usability have been cited as the biggest obstacles to adoption of health IT – especially Electronic Health Records (EHR) systems – and has resulted in problematically-low EHR adoption rates. Eliminating this cost, and the IT maintenance burdens that are often beyond the reach of small medical practices, clearly removes these significant roadblocks to EHR adoption.

What about safety? There are several issues around safety of health data which should be separately considered.

1. Data safety in the event of disaster-recovery is better when the data is hosted, in a “cloud.” With local data installation, and certainly with paper records, a local disaster (building fire, tornado, hurricane, etc.) can wipe out local data. The only point of failure in a cloud-based approach is loss of internet access. Redundancy of internet access (hard lines, wireless, cell-phone) is recommended to minimize this risk.
2. Security of the data from the standpoint of malicious hacks. Compared to locally-housed resources, “cloud” services typically improves security because SaaS providers (like Practice Fusion) are able to devote resources to solving security issues that many customers cannot afford. This has been the subject of a recent Practice Fusion blog post. By implementing high-level encryption across connections, as well as housing the data in a dis-aggregated and encrypted structure, the Practice Fusion "cloud" implements all the security requirements resulting from HHS "meaningful use" criteria.
3. Privacy of data. Access to medical data is tightly controlled, and Practice Fusion has devoted much attention to this. Especially in an environment where a patient’s EHR data might be shared between practices taking care of that patient, and where EHR data is shared with a patient-centered Personal Health Record (see here for a discussion of these terms), diligent attention to privacy and permissions must be at the root of a “cloud”-hosted EHR or PHR system.

The approach to EHRs and PHRs that has been charted by Practice Fusion, and is significantly enhanced by Salesforce.com’s expertise and resources, is a tremendously positive step for everyone. Elimination of barriers to EHR adoption, while at the same time ensuring security and privacy of protected health information, are all positive results of using the “cloud” approach. They will move us all toward the true intent of “Meaningful Use” of EHRs – the basis of the federal stimulus around the emerging national health IT policy.

Robert Rowley, MD – Chief Medical Officer, Practice Fusion, Inc.

How secure is my EHR data?

The benefits of digital medical records are tremendous – both in the improvement of quality of care, as well as in the reduction of unnecessary cost to deliver that care. Measuring healthcare-delivery quality – reporting on items defined by various organizations (PQRI, HEDIS) as well as by the HHS Meaningful Use criteria – simply cannot be done without the availability of electronic health records.

Insuring security and privacy, of course, are critical with any digitized personal information – just like banking information, personal checkbook information backed up online, and many other financial and insurance information available today. In fact, an entire domain of the newly-defined HHS Meaningful Use criteria (which will be used as a basis upon which to certify electronic health record (EHR) systems) is around security and privacy. Standards are being defined for encryption and for disaggregation of health data so that simple hacking into a database yields meaningless results.

The result of all of this is that electronic records which comply with the HHS Meaningful Use criteria are safer than paper. Yes, the scope of potential theft of paper health data is smaller and more local – but easier to do. More aggregated sources of health data are potentially larger targets for thieves, but the locks are better.

Further, locally-installed EHRs are potentially more susceptible to hacking if the local installation does not have adequate security. Laptops which contain actual personal health data might exist in these scenarios, and could potentially be stolen and used. Many of the traditional, legacy EHRs are built around local installation, and would rely on each local clinic to build their security – this might be expensive and some local installations may simply not do that.

Web-hosted, SaaS-based (software-as-a-service) EHRs have the advantage of having no personal health data housed in local machines. At Practice Fusion, we have placed a great deal of attention to the question of security – housing data in world-class servers with biometric security, multi-geography backups and failover to reduce the risk of data loss in case of a natural disaster. Full compliance with HHS criteria, HIPAA and additional risk reduction beyond these “mandated minimums” has been at our core, so that what is offered to our physicians is the highest level of security available – and it is available to all practice size, even solo practices, as a free service.

With good design, the risks of health-data security can be mitigated. When weighed against the benefits of electronic health data, and the impact of that on improved healthcare, the future outlook is, in fact, quite an optimistic one.

Robert Rowley, MD - Chief Medical Officer, Practice Fusion, Inc.

EHRs, PHRs and Patient Portals – how are they connected?

An increasing amount of attention is being focused on Personal Health Records (PHRs), and how these relate to Electronic Health Records (EHRs). Australia, for example, has set a goal for every citizen to have a PHR by 2012. With a myriad of terms being used in the press around elements of health IT, it might be useful to review what they are, and how they are related.

The terms EMR (Electronic Medical Records) and EHR are often used synonymously, but many define EMR as just the physician interface, and EHR includes both a physician and a patient interface. The main idea here is that EMRs/EHRs serve as tools designed for physicians, and attempts to replace the use of traditional paper charts in a medical office. A well-designed EMR system will work harmoniously with workflows in a physician office, and will ease the time and burden involved in medico-legal documentation of patient encounters. An EMR may interface with a Practice Management (PM) system, which carries out billing. PM systems, sometimes housed in-house and sometimes housed in outsourced billing agencies, are responsible for packaging billing information, sending out bills to insurers (via paper or electronically), posting payments, and sending out patient bills. Often, PM systems are stand-alone, and sometimes are part of an EMR-PM integrated system.

As EMRs have matured, many have offered Patient Portals – web-based ways in which patients can view some of the information contained in their physician’s EMR. When a Patient Portal is added to an EMR, it is often then called an EHR. Patient Portals are populated by EMR data, and not updatable by the patient directly. Kaiser’s KP Online is an example of such an offering. Such Patient Portals may contain ways by which patients can communicate via secure email/messaging with their physicians, receive lab results, request appointments or pay their bills.

Patient-centered documentation has grown in parallel to EMRs. Though the precise definition has undergone evolution, a PHR has come to imply a computerized application that stores an individual’s personal health information (like allergies and adverse drug reactions, medications, illnesses and hospitalizations, surgeries and other procedures, vaccinations, lab test results, and family history). The idea is that a PHR is portable, controlled by the patient, and serves as a repository of data that can be referred to when encountering the healthcare system in a variety of settings (like going to a new doctor, or a hospital, or an emergency department).

Traditionally, PHRs began as simple, empty shells, and relied on patients to enter all their information themselves. Not surprisingly, such efforts were only taken up by a few “early adopter” enthusiasts, and failed to gain widespread usage. More recently, a newer generation of PHRs have emerged (Google Health and Microsoft Health Vault), which offer the ability to fill PHR data from outside data-source feeds, such as lab results. Unfortunately, much of the available data imported by these PHRs had come from health-plan data, based on billing (not clinical) information, which was found to be significantly inaccurate.

What is the future of these trends? PHRs and EHRs have been converging, and this will continue to evolve. EHR Patient Portals have the limitation of being only about what is contained in a given practitioner’s system (what happens to your Kaiser Patient Portal when you leave the Kaiser system?), though they have the advantage of being pre-populated by the clinicians’ EMR data. PHRs, more portable and centered around the patient (regardless of where healthcare is sought), have tried to be more connected, and filled by EHR data where possible. The ideal is to create a PHR that is filled by data drawn from each EHR system used by the various clinicians involved, allowing patient feedback and involvement – and done in a way that is secure and protects privacy.

The federal government is building a Nationwide Health Information Network with this goal in mind. Some traditional EHR vendors are building their own infrastructure to help in this effort around Health Information Exchange (HIE). Practice Fusion is moving in that direction as well – by building the ability for clinicians to share charts across different practices, the Patient Portal under construction will in fact be a PHR pre-populated by the EHR data from all the clinicians involved in care, and available securely via a web connection – and, importantly, available as a free service facilitated by the underlying Practice Fusion business model.
 
Robert Rowley, MD – Chief Medical Officer, Practice Fusion Inc.

The conversion from paper to EHR – how much does it REALLY need to cost?

The topic of converting medical practice from paper to electronics seems to appear daily in news, blogs, radio, and seemingly everywhere. Earlier this week, NPR's Marketplace had a segment about the costs of implementing an EHR.

Several factors have brought this question to light: ARRA stimulus money set aside to encourage physicians to take on e-adoption (up to $44,000 cumulatively from 2011 to 2015, as an add-on to Medicare payments): the emergence of a national Health IT policy that defines goals, objectives and “meaningful use;” and the debate around federal health reform – all these factors add juice to adoption of EHRs.

 

One of the presumptions in the discussion has been that EHRs are expensive. Several studies have shown that the biggest barriers to EHR adoption historically have been (1) cost, and (2) usability (or the lack of it). Traditional EHR vendors have offered very large, self-contained, locally-installed client/server systems – and these systems have been very costly. Not only is there the cost of the EHR software itself, but there is the cost and burden of establishing a server, with data backups, security, connectivity and the like. This is something beyond the resources available to smaller practices, and therefore (not surprisingly) such EHRs have been implemented in larger organizations: hospital-based systems, large medical groups, staff-model organization like Kaiser, etc.

 

But how much does an EHR need to cost, really? Firstly, a locally-installed client/server system involves server-end costs. Even if that EHR software were given away free, the server costs remain – and this is considerable. Again, a major challenge to small practices. However, web-based, hosted EHRs completely remove this layer of burden from the practice. No longer are there server-maintenance, data backup, security, and network connectivity issues – all you need is an internet-connected computer and a browser.

 

Even beyond the benefits of a hosted, web-based “software as a service” (SaaS), there is also the question of paying for the service. Some SaaS-based EHR vendors charge a monthly use fee, sometimes per-MD and sometimes per-user. Practice Fusion has developed a unique business model that allows the SaaS service to be offered for free to all end-users. Revenues come from ads, and other alternative revenue sources.

 

By eliminating the cost barrier of EHR adoption, Practice Fusion can focus on the issues that are truly significant – usability, flexibility, portability, connectivity to other data sources, and true establishment of “meaningful use.”

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

The debate over EHR certification

As the national Health IT Policy committee continues to develop a policy around “meaningful use,” the debate on what criteria should be used to deem an EHR as “certified” has been heating up. The Certification/Adoption workgroup held hearings on July 14 and 15, and testimony there illustrated significant debate on the role that CCHIT (the legacy certification body for EHRs) should play in the new era.

 

CCHIT developed certification criteria in a national policy vacuum, and (not surprisingly) created criteria that were largely feature-focused. Large legacy EHR vendors, via their trade organization (HIMSS), created and spun off CCHIT, and developed a criteria-set in 3 domains: functionality (what specific features were included in the software), interoperability (which was about fairly low-level data exchange capabilities between systems) and security (a superset of HIPAA). It did not address anything about usability, or outcomes.

 

In the current era, where ARRA moneys are earmarked for health IT adoption (HITECH), the Office of the National Coordinator for Health IT (ONCHIT, or ONC for short) has developed policy focused on results – on “meaningful use” of technology. In its July 16 meeting, the HIT Policy Committee has defined its views around certification a little more. They propose a new term: “HHS Certification,” which is to mean a system that is able to achieve government requirements for security, privacy and interoperability, and would enable the Meaningful Use results that the government expects. Certification should flow from the Meaningful Use criteria, and be carried out in a way that is much more flexible than has occurred in the past. 

 

At Practice Fusion, we applaud the direction being charted by ONCHIT. The emerging certification criteria, focused around achieving Meaningful Use, gives us an opportunity to build systems that have true value. This year presents a unique window of opportunity to “get it right” and create tools that can actually facilitate a transformed healthcare delivery system.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

“Computerized Physician Order Entry” – what does it all mean?

“Computerized Physician Order Entry” (CPOE) has become a bit of a buzz-word in Heath IT circles, stemming from a focus on this in the emerging national Health IT policy. One of the areas of “meaningful use” described in the health IT Meaningful Use Matrix encourages the use of CPOE. Exactly how to measure usage, however, is a bit problematic – how can you determine the percentage of “orders” which could have been done electronically that were, in fact, done that way? How do you capture a denominator, given that “orders” not done electronically were presumably done via paper or other manual methods, and would not be available to be counted by electronic systems.

 

Much of the desire to have CPOE be a national “meaningful use” criteria stems from a study in the journal Radiology which show that CPOE, when combined with Decision Support (DS) significantly reduces the growth in utilization of high-end imaging (MRIs and PET scans). The data is quite compelling that such systems make a real difference.

Further complicating this issue is that Computerized Physician Order Entry means different things in an inpatient vs. outpatient setting. Filling out a “physician’s orders” sheet is a familiar workflow in an inpatient setting, where a ward clerk takes entries from the order sheet and turns them into directives for care (imaging, pharmacy, nursing, etc.) – replacing this workflow with a CPOE system is an easy transition, mimicking traditional workflows. It also creates a framework where decision support (DS) can be introduced, and data-driven “standing order sets” for specific situations can be called upon.

 

In an outpatient setting however, there is no equivalent of a “physician’s order” sheet. Instead, physician directives are handled through a variety of messages. A messaging system serves as the platform for response to incoming messages (e.g. handling patient incoming phone calls, or incoming requests for refills from pharmacies), as well as outbound work-orders (e.g. follow-up appointment scheduling, ordering imaging studies, ordering lab tests, issuing prescriptions [de novo or refills], nursing orders, referrals). 

Therefore, when defining “CPOE” for an ambulatory EHR, specific order types (message types) should be defined in the certification criteria – radiology/imaging requests, lab order requests, electronic prescribing, referral generation, follow-up scheduling, etc. Additional message types in an ambulatory setting (e.g. responding back to patient phone calls or emails) may also exist, though not strictly “CPOE” in this sense. Such a messaging platform can subsequently serve as the place where decision support (DS) can be introduced.

 

This field, motivated by powerful incentives and compelling data, is evolving as the Health IT Policy Committee starts translating “meaningful use” into certification criteria, and defining exactly what and how CPOE is to be measured. The window of opportunity for input into this process is certainly here, and Practice Fusion will remain an active participant in this discussion.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

The emergence of a national health IT policy

The American Recovery and Reinvestment Act (ARRA) creates  the framework for a national health IT policy. Such a policy has never previously existed. In order to develop such a policy, a new set of federal advisory committees has been convened – the Health IT Policy Committee has now met and has reported its findings to date here.

 

In a short amount of time, the Health IT Policy Committee has developed a very positive framework that helps IT developers (such as Practice Fusion) gear their efforts in a consistently meaningful direction. The HIT policy started with an “ultimate vision to enable significant and measurable improvements in population health through a transformed health care delivery system.” Adapted from the National Priorities Partnership, several overall goals have been identified: (1) improve quality, safety and efficiency; (2) engage patients and their families; (3) improve care coordination; (4) improve population and public health, and reduce disparities; and (5) ensure privacy and security protection. This overall vision is described in a “meaningful use preamble” document.

 

For each of these Health Outcomes Policy Priorities, a series of Care Goals have been defined in a “meaningful use matrix.” And for each of these Care Goals, a series of Objectives for 2011, 2103 and 2015 have been proposed, as well as Measures associated with these Objectives by which to determine “meaningful use.”

 

Actual detailed Certification Criteria are currently being defined, and will be derived from the Objectives. Practice Fusion has been engaged in this process and has submitted commentary to the committee.

 

The traditional certification criteria for EHRs has come from CCHIT, a non-profit agency that grew out of an EHR vendor trade organization (HIMSS), but was spun-off as an independent agency. CCHIT had been designated as the sole certification pathway for EHRs prior to ARRA. However, the certification criteria developed by CCHIT since 2006 were developed in the absence of a guiding national health IT policy. Such criteria could be characterized as being more product-centric than results-oriented.

 

The newly created Meaningful Use Objectives, from which new certification criteria will be derived, commendably is more focused on results than any particular “functionality” characteristics of the software. It is as yet unclear how the certification process will be carried out, and what role CCHIT will play in this process, but what is becoming clear is this: in order for EHRs to be examples of “enabling technology” that will truly transform healthcare, “what counts are results.” Practice Fusion remains committed to engaging this process and developing products that will satisfy all the “meaningful use” criteria and truly help enable a transformed healthcare system.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

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“Meaningful use” and what it means to physicians

The Obama administration’s massive stimulus package (known as ARRA) contains a section pertaining to the adoption of electronic health records (known as HITECH), and earmarks substantial money (up to $44K per physician over the next 5 years) for physicians who can demonstrate “meaningful use of certified EHRs.” Defining what exactly is meant by “meaningful use” has been the focus of intensive debate as the newly-created government bodies charged with oversight of this have begun deliberation. The exact definition of “meaningful use” should be hammered out by the end of 2009, with incentives beginning to become available to physicians in the subsequent years.

 

“Certification” has similarly been a subject of much debate. Traditionally, CCHIT has been the sole certifying body for EHRs, emerging as a non-profit agency spun off from a government-industry collaborative. Many have assumed that CCHIT will remain as the going-forward certification body, but others have questioned this and propose that alternatives to certification are appropriate. They argue that, besides the $30K certification price tag, CCHIT developed its criteria in an era when large, self-contained client/server EHR systems were emerging, and that such criteria lose relevance in a web-based, distributed, cloud-oriented environment – such as the one that Practice Fusion has emerged in. CCHIT wants to modernize its criteria, but it may lag behind technological innovation.

 

Regardless of how certification will emerge, it is clear that “certified EHR” and “meaningful use” will be closely linked. In order to qualify for “meaningful use,” an EHR should be able to do the following:

1.     Electronic prescribing, both out-bound e-prescribing of new, de novo prescriptions, as well as responding to prescription refill requests originated by pharmacies

2.     Achieve interoperability, meaning that summary data (diagnoses, medications, allergies, etc.) can be easily exchanged with others using different EHRs. There is a standard type of document, called a Continuity of Care Document (CCD) which needs to be able to be created and exported, as well as imported.

3.     Generate quality reporting and metrics. The criteria set has yet to be determined, but is likely to be either the HEDIS set of metrics (used by insurers in the private domain) or the larger PQRI set (used by Medicare, and which encompasses the HEDIS criteria plus many more)

4.     Point of care decision support. This will be a technology that evolves, starting with simple things like prompting for wellness and chronic-disease management prompts, but evolving into presenting physicians with evidence-based guidelines for the diagnosis at-hand.

5.     Routine, secure, electronic communications between patients and caregivers. This can include prevention and screening reminders, and numerous other ways of supporting patients in their own management of their own health.

 

The specifics of all of this, of course, will be hammered out in the debate process this year. Practice Fusion is keeping a very close eye on all of this, and is rapidly building features in each of these categories. Our goal is to offer physicians a robust EHR that is not only free to use, but also will qualify everyone for “meaningful use” as this definition becomes clearer. Whether CCHIT remains the sole certifying channel, or whether it becomes one of several avenues towards certification, Practice Fusion intends to achieve “certification” as ultimately is defined by HITECH.

 

Robert Rowley, MD

Chief Medical Officer

Practice Fusion, Inc.

Follow us on Twitter: #practicefusion