A Top MD and EHR Leader Sheds Light on the Confusion

Leslie Kane, MA: Hi. I'm Leslie Kane, Executive Editor of Medscape Business of Medicine.

Electronic health records (EHRs) have become a large part of physician's lives, and attesting for meaningful use is a major activity lately. One component of meaningful use is having a certified EHR, but there is a lot of confusion about the relationship between EHR certification and meaningful use. There is confusion about what physicians need to do to attest for meaningful use.

To clarify some of these issues and discuss this further, we are here with Dr. Karen Bell, who is Chair of the Certification Commission for Health Information Technology (CCHIT). This was one of the first organizations to certify EHRs. Hi, Karen; thanks very much for being with us today.

Karen M. Bell, MD: Thank you so much Leslie, it is truly a pleasure to be here with you.

Ms. Kane: For an EHR to be certified, the EHR has to be able to do certain things, but meaningful use has more to do with how a physician uses the EHR. Has that caused a degree of confusion among users?

Dr. Bell: The entire program can be quite confusing, because physicians have expectations for everything from certification, all the way up to the payment mechanisms. Until they understand what this entire program is about -- soup to nuts, certification to payment -- they are unlikely to be able to actually get to that attestation piece. Right now, 50% of physicians who could be applying for meaningful use have registered to do so, but only about 20% have actually gotten to the attestation point.

Ms. Kane: What key areas have you noticed, or heard of, that people are having more trouble understanding than others?

Dr. Bell: The certification is probably one of the biggest areas. A lot of this has to do with the fact that in general, most physicians are board-certified these days. To go through that certification process, you must study tremendously, and you truly become an expert in your field. The expectation that there is some sort of expert review of an EHR that will meet all of your needs in the clinical setting is out there. However, the Office of the National Coordinator (ONC) for Healthcare Information Technology certification process, by federal law, is limited to what is necessary to meet the meaningful use measures. So, the EHRs that are certified just to meaningful use may not meet all of their expectations. That is one problem.

The other problem is that there are several different certification programs out there. That is probably the biggest issue, and it has been quite confusing for a lot of physicians as well. They are caught between these 2 prongs at the moment.

Ms. Kane: The ONC has set certain standards for certifying an EHR. There are 5 groups, in addition to yours, that are certifying EHRs. I understand that CCHIT has 2 sets of criteria for certifying an EHR. What are the different sets of criteria, and what do they mean to physicians and users?

Dr. Bell: We have 2 very different programs. We do the work that ONC has requested that we do. We also certify the EHR to a very different set of criteria that were developed by more than 300 subject matter experts in the field, to better meet the needs of clinical care.

Our own programs not only do ambulatory EHRs and inpatient EHRs with that very specific mission of consumer protection, but we also do specialty EHRs, such as cardiology, women's health, dermatology, and a few others. Those programs incorporate the integration that we believe is necessary for clinicians to use.

These programs also include some testing for usability. We do not offer final certification unless the product is actually in use in the clinical setting, as opposed to something that was developed and never used.

We have a very intensive program that we certify to, on the basis of our own criteria that were developed by the subject matter experts, which some people believe is a fairly high bar. We also certify to the government's criteria, where the mission is both limiting to the federally necessary meaningful use and stimulating innovation, to allow a lot more products to come to the market.

The bottom line is that 1000 ambulatory EHR products are available right now under the government's programs. Some 600 of them are complete EHRs, and 400 are modules. It is like the Wild West out there for the physicians.

Ms. Kane: Interesting. I understand that one way that EHRs can be certified is for the individual modules to be certified, and that way the EHR will be certified. However, it is possible that the modules ultimately won't all work together. Physicians may not be aware that this could happen. What is this about, how can this happen, and how do you guard against it?

Dr. Bell: The CCHIT goal is to make sure that this works for patient care. Clearly, if it's going to work for patient care, all the bits and pieces have to work together.

The real goals of the ONC program were 2-fold. One was to do the meaningful use measures, and the second was to stimulate innovation. The CCHIT program was thought by some to be too high a bar. A lot of the up-and-coming companies felt that the criteria that we had developed were above and beyond what they wanted to do in the market.

This new program -- the ONC program -- was based on modules, meaning that every single criterion could constitute 1 module. You could get an EHR that had all the criteria in it, but you could also put together a dozen different pieces of technology, each one with a different set of criteria. However, there was no guarantee that the modules would integrate. That responsibility goes to the doctor or the hospital. They either have to pay about $5000 per interface to knit all this together, or they have to be facile in doing it themselves.

Ms. Kane: I can see why that would be problem for a lot of people. Medscape recently did a survey. It showed that 48% of physicians who had EHRs said that they expected that attesting for meaningful use would either be difficult or very difficult. Are they right?

Dr. Bell: It depends on where they are starting. If they are starting from paper, it's going to be extraordinarily difficult, and they probably will not be able to do it without help. There is a program, the Regional Extension Center Program, of the federal government that offers help to a limited number of physicians. There are delivery systems that offer support to physicians and providers.

To do it alone means going through the whole process of deciding what you want, how it will work in your practice, what it's going to cost, getting all the right hardware, and redesigning your office. It's not just changing how it's set up physically, but also redesigning everyone's job descriptions. It's a huge piece of work.

To go from paper to meaningful use is extraordinarily difficult. Once you have done that, you also have to make sure that there are other systems in place to achieve meaningful use. You have to be able to share information with other physicians, or with the Health Department. All of these pieces have to come together, and that is why it is so difficult.

Ms. Kane: Many physicians have already attested for stage 1 meaningful use, and in 2014, stage 2 meaningful use will come up. What will that mean for the physicians who have attested, and for physicians in general?

Dr. Bell: To be honest, Leslie, we don't know, because the final rule isn't out yet. There was a proposed rule that came out at the end of February. There has been a lot of public comment on that, from very large organizations (such as the American Medical Association) and from individuals. What we are going to see in the 2014 edition is still under wraps. Having said that, and having seen what has been proposed, there is no question that stage 2 is going to raise the bar even higher, and it does it primarily by focusing on 2 areas.

One is health information exchange. There will be requirements for more in the way of health information exchange. The second is the area of patient engagement. Physicians will have to communicate more with their patients and provide more information to their patients, and in many ways will be held accountable for the patient's actions. There has been a lot of pushback on that also. That is one of the reasons that many physicians feel it is going to be difficult.

Ms. Kane: Do you have any sense of when the final rule might be out?

Dr. Bell: It has been promised by the end of summer, about the third week of September, but who knows? We could get a surprise.

Ms. Kane: I understand that a new edition of certification criteria will come out this summer. What is different about it, and how does it affect the doctors and practices that already have EHRs?

Dr. Bell: It is a difficult situation because the timing is such that the criteria will come out, and then the organizations that will be certifying the 2014 edition will have to start immediately going through the process. For the first edition, some 600 complete EHRs plus another 400 modules were certified. So, on the ambulatory side, we are talking about 1000 pieces of technology that will either have to be updated, or will go under one way or another. The developers will have to do a lot of work on the new edition. The bodies that do certification will have to start certifying. I honestly don't see these on the market much before the early part of 2013.

Ms. Kane: It seems that there is a ton of activity in this area between the certifications and stages of meaningful use. It is puzzling for a lot of people. What advice would you have for physicians who are considering purchasing an EHR, or working with EHRs? What would you say to them?

Dr. Bell: It depends on where they are right now. Obviously, if they don't have an EHR, they are going to start at stage 1.

One very important point is that there is no connection between the stage of meaningful use and the certification edition. In January of 2014, a physician must have EHRs that are certified to the 2014 edition criteria, regardless of whether they are going to do stage 1 or stage 2 of meaningful use. Before 2014, they can do stage 1 or stage 2 using the 2011 edition.

It will require a lot of business planning to think through when is the best time to move into a 2014 edition. If you don't have an EHR right now, you might want to wait until January, because then you will have an edition that will be good for a while. If you have an EHR already and it's already certified, you will want to make sure that it is updated and upgraded, so you should coordinate with your vendor right now to develop a game plan for updating your EHRs.

Ms. Kane: Are there any other aspects that physicians should pay attention to? Do you think we've covered it?

Dr. Bell: We covered the certification pretty well. It will still be confusing for a while. One of the areas that many of us are concerned about is that on the ambulatory side, there are 600 products out there. Not all of them have been used in attestation. So, it is unclear what the market is going to do with all of these products going forward, whether all of them are going to go to the 2014 edition, and whether they are going to viable long-term. It is still a "buyer beware" environment. The more information you can get, the more you can keep up with everything through the Websites, the better off you will be.

Ms. Kane: Thanks, Karen, for taking the time to be with us today, and giving us all your insights and terrific information.

Dr. Bell: Thank you Leslie, it was truly a pleasure.

Ms. Kane: We're very grateful to Dr. Bell for spending time with us, and clarifying a lot of important issues. I'm Leslie Kane; thank you for joining us.