Providers and vendors: Simplify EHR certification, advance interoperability

The need to improve EHR usability, advance interoperability, and both simplify and slow down the timeline when it comes to the Office of the National Coordinator for Health IT’s certification and the Centers for Medicare & Medicaid's Meaningful Use program all emerged as major themes during provider and vendor panel discussions held by the Health IT Policy Committee (HITPC) certification & adoption workgroup on May 7. Also, many expressed concern that IT resources dedicated to EHR certification and MU hindered innovation efforts.

The HITPC hosted the hearing on ONC’s health IT certification program to evaluate its performance to date and solicit feedback from industry stakeholders on possible improvements. The workgroup is expected to pass along their recommendations to the greater HITPC after another meeting scheduled on May 8.

“Our purpose is to be forward-looking, understand how things are looking and how to improve the program to accomplish things we need to work on in new care models and, most importantly, to be interoperable to exchange data in a meaningful way. That’s the approach we’d like to take,” said Paul Tang, HITPC vice chair, during the meeting’s introduction.

Providers and vendors made a resounding plea to simplify the program, with the word “prescriptive” commonly used to describe the program.

Certification should not be an attempt to test every single variation of data entry, but should focus deeply on a few areas, like interoperability and quality, as opposed to test procedures, said John D. Halamka, MD, CIO of Beth Israel Deaconess Medical Center in Boston.

Many providers shared the sentiment that EHR certification should be a means to providing higher quality, safer and more effective care.  But, often EHR software dictates workflows that do not mesh well with clinical practices while usability is not optimized.

“Usability issues are a huge part of the problem. The certification process means that vendors are currently geared toward checking boxes on functionalities but not how effective it is for the user,” said John Berneike, MD, of the Utah HealthCare Institute.

“The fact that one checked a box and was able to get through procedures and scripts doesn’t mean the clinician could achieve policy goals to achieve outcomes,” said Halamka.

The program should be redesigned to put more burden on vendors, not less, said Chad Jensen, manager of human resources and IT at LaTouche Pediatrics. Jensen suggested more availability of like-to-like functionality and workflow comparisons of different EHR products, and noted that the assumed workflows established in certified EHR products do not always work in all clinical settings.

For their part, vendor representatives said the compressed timeframe to push out certified products interfered with their ability to optimize usability and develop functions specifically requested by their customers.

“We have lost our ability to innovate on anything above and beyond the mandates of Meaningful Use. Since embarking upon this program we have been unable to devote resources to features which our customers are requesting,” said Joseph Geretz, chief software architect at SRSsoft. “Our customers ultimately bear this burden in terms of higher costs and lost productivity, as the program--with its tight deadlines--trumps our focus on ease of use and productivity.”

The effort invested into the program is greater than the value achieved from the program, said Sasha TerMaat, a project manager for Epic, in her testimony. EHR vendor investment in understanding the certification process and requirements and programming new features or necessary changes in their software and readying their demonstration systems for certified testing take considerable time and resources.

“This investment, of taxpayer dollars invested in the regulatory processes and tools, of the EHR developer’s time and money not spent on other user-prioritized features, and of the resources spent by healthcare organizations not dedicated to other initiatives, must be merited by the value certification provides,” she said.

Cletis Earle, vice president and chief information officer at St. Luke’s Cornwall Hospital, said that vendors often are “behind the 8-ball” when it comes to providing codes. “When going to Meaningful Use Stage 2, we had over 10,000 patches we had to go through, and three months later we had another revision with 6,000 to 8,000 patches,” he said, adding that his organization lacks the resources to cope with all the updates.

Certification should do more to address the quality of code, said Colin Banas, MD, CMIO at Virginia Commonwealth University (VCU) Health System. “Vendors have to provide high quality software.”

Banas also talked about the “continued blurred lines” between certification and the steps needed to receive attestation. “There is no guarantee that a certified program will achieve Meaningful Use measures,” he said.

He also called the certification program unduly burdensome, especially at VCU, which established its own EHR that can achieve MU measures but perhaps not in the prescribed path required by federal agencies. “There should be more flexibility,” he said. “Shouldn’t those participating in a state HIE get credit for transfer of care? If VCU contributes CCDAs to it, then everyone in the commonwealth can get access to those. That’s better than getting a Direct address and praying to God that one HISP can talk to another HISP. So why not trade through HIEs instead of getting so granular with numerators and denominators?”

Echoing that thought, Ginny Lorenzi, manager of health IT standards and collaborations at NewYork-Presbyterian Hospital, said providers need more support achieving MU attestation with the certified programs they have. Once a provider has certified EHR, “you get the football half way down the field and then you are on your own.”

Lorenzi said all the requirements have created a culture of fear, in particular of audits, and has driven up stress levels of clinical staff.

Mickey McGlynn, EHR Association chair, called for the initiation of a holistic kaizen process to review the combined MU and certification programs, with many vendors participating in the talks offering to participate.

“Developers are working so fast to meet the demands of Meaningful Use, that time is lost to life-saving innovation,” added Marc Probst, CIO of Intermountain Healthcare, which uses its own homegrown EHR.

He suggested doing away with the certification program altogether. “It’s a boat anchor the world could do without.”