GOVERNMENT INTERVENTION IN EHR MARKET

The government intervened in the U.S. electronic health records (EHR) market by creating the Commission for Certification of Health Information Technology (CCHIT). CCHIT subsequently developed standards for what minimal functionality an EHR 'should have', based on inputs from physician proxy group and very large EHR vendors. The first release of their STANDARD has now been issued and fees set for EHR developers to 'certify' that their systems meet the CCHIT standard. The initial batch of EHR developers have now been certified. The process has so far proved expensive and will get more so as the standards are expanded to the inpatient setting and to meet the needs of various specialties. EHR developers need to budget at least $28K initial certification fee per EHR product and $42K cumulative fees over 3 years for each EHR product they produce, as well being prepared to undertake all the associated indirect costs. It seems clear therefore that CCHIT will create upward pressure on EHR developer pricing in the near future and becomes an ever-larger government-initiated bureaucracy. The Commission has not accelerated the adoption of EHR as it was created to do, but rather has slowed it and made EHR products more expensive because of the approach it has taken.

WHY COST IS IMPORTANT

Cost is an important issue to both physician group practices and EHR developers, as group practices consistently list high initial cost as one of the most important barriers to their adoption of EHR solutions. In research published in the Sept./Oct. 2005 issue of Health Affairs, the average cost for EHR systems adopted to date was reported to be $33K per physician for initial purchase and $1,200 per month per physician for ongoing support agreement. These cost figures were compiled before CCHIT issued its standard or announced vendor fees for system certification. So the costs of becoming a 'certified' supplier will increase EHR developers direct and indirect expenses, which will ultimately be passed on to physician group practices purchasing these systems in the form of price increases.

STRENGTHS OF THE STANDARDIZATION APPROACH

CCHIT's approach to date has been totally focused on creating a VERY BASIC FUNCTIONAL EHR standard and then certifying EHR systems that meet it. That approach has the strength of assuring that ALL EHR products meet minimal criteria, however because many EHR systems go well beyond such basic features, CCHIT is weak in addressing EHR vaporware. EHR developers are free to offer features that go beyond those specified in the CCHIT standard, features that are not verified by the CCHIT certification process, CCHIT will never effectively address the EHR 'vaporware' issue, which is better addressed by the complementary approach of EHR verification. This failure to eliminate vaporware remains an important concern if physicians looking to purchase EHR solutions are no longer to be concerned that promised features may not be delivered or even exist in the system they purchase.

VERIFICATION PROPOSED AS AN ANSWER TO THE VAPORWARE CHALLENGE

To address the issue of vaporware, Medical Strategic Planning, Inc. (MSP) and others are proposing the industry adopt 3rd party, independent verification of systems being sold by EHR developers. This approach, which could be seen as complementary or supplemental to CCHIT certification, asks an EHR developer to complete a benchmark of the features provided in their EHR products and provides a list of customer sites (none of which can be development partners), at which all of the benchmark features are installed and fully operational. A third party market research company then contacts these client sites and verifies that the features listed in the EHR benchmark, in fact do exist and are fully functional in the EHR developer's product. Any feature that cannot be verified is then dropped from the benchmark of verified features that a vendor can claim to provide. The verification approach therefore gets at issues that any standardization approach is not as well equipped to address. Verification covers a much broader set of features, essentially all features claimed by an EHR vendor, so is more likely to also uncover and address issues of erroneous manual data entry and other issues, that standardization has not yet addressed. Best of all, verification can be accomplished for about 1/5th the cost of certification to standards, once an EHR feature repository exists of all major systems. MSP has created such a repository of over 2,100 features for 104 major EHR system developers currently marketing in the U.S. physician office arena.

WHAT ARE THE CRITICAL PROBLEMS?

MSP studies of group practices and other market research published and presented at various conferences, have identified barriers to EHR adoption by group practices. Indeed, some of these are enumerated also by the EHR developers themselves, as reported in the 11th Annual Andrew & Associates EHR Benchmark study conducted in 2005 and available on this website to browsers who log into either this EHR special interest group or to EHR developers who log into the Andrew & Associates EHR Benchmark survey or to medical device and information systems sections of this website. It cover the majority of the 2006 EHR Benchmark in 168 pages that include 126 figures, discussing IOM, HL7-CDA, ASTM-CCR, HIE, HIPAA, quality and other key sections of the EHR products currently on the market. It is critical reading to EHR developers, EHR consultants, physician advocacy groups, national healthcare planners, quality organizations and others who are interested in understanding or setting standards for the capabilities of EHR products.

HOW WELL AVAILABLE SOLUTION 'FIT' MARKET NEEDS?

Given the market needs of:

1)  Having EHR functionality that 'fits' each practice specialty

2)  Lowering, but certainly not increasing the cost of EHR systems

3)  Eliminating vaporware and bringing integrity to EHR developer claims BEFORE deployment

4)  Creating interoperability among ALL EHR vendors, so that clinical data can migrate from one system to another

It is illuminating to compare the two approaches of EHR VERIFICATION and EHR CERTIFICATION to a standard feature set specified by CCHIT.

The above table suggests that on several important factors, independent verification when used with certification addresses a much wider group of concerns that any standards/certification approach alone achieves. For their to be true buyer confidence in the market, BOTH approaches must be adopted, as they are complementary.

YOUR OPPORTUNITY TO WEIGH IN

We invite discussion of this issue among EHR developers and other interested and informed parties. If you have an opinion on this matter, write a letter to the Editor of our Industry Alert™ newsletter and submit it to us by email. We welcome your feedback.