October 10, 2011

To EACH His Own
By Robert J. Murphy
For The Record
Vol. 23 No. 18 P. 14

The EHR Alternative Certification for Hospitals program allows organizations to take a road less traveled toward meaningful use.

In a time when meeting meaningful use requirements is at or near the top of most healthcare organizations’ to-do lists, facilities are taking various paths to achieving their goals. For example, in September, another of the nation’s hospitals joined the small but growing number of healthcare organizations that have certified their EHRs through the EHR Alternative Certification for Hospitals (EACH) program developed by the Certification Commission for Health Information Technology (CCHIT). By doing so, they took the first step in satisfying the meaningful use requirements necessary to obtain federal incentive payments.

EACH is designed for hospitals that have uncertified legacy software, customized commercial products, or self-developed EHR systems. Instead of relying on vendor-certified products, these organizations take a homegrown approach.

As of mid-September, 10 providers have achieved the distinction since the program was introduced at the beginning of this year. Joining Boston’s Beth Israel Deaconess Medical Center, which was the first to receive complete EHR certification under the program, are the following providers:

• Health Management Associates (modular EHR); 

• New York University Langone Medical Center (complete EHR);

• Northwestern University (modular EHR);

• Tenet Healthsystem Medical (modular EHR);

• University of North Carolina HealthCare (complete EHR);

• Boston Medical Center (complete EHR);

• Sharp Healthcare (modular EHR);

• MD Anderson Cancer Center (complete EHR); and

• MedMagic LLC (complete EHR).

According to the CCHIT, the EACH program is designed to evaluate how an organization’s technology measures up to meaningful use certification requirements and allows it to pursue certification of any existing EHR that’s not vendor certified.

The CCHIT believes the program fills a gap in the meaningful use equation. “Most hospitals and hospital systems—and some large group practices—are complex and rarely deploy one vendor’s system exclusively; they have an interconnected ‘system of systems,’” says Patricia Becker, certification director at the CCHIT. “The deployed EHRs in these complex systems are often a mix of commercial and self-developed software. In these cases, the model of obtaining certified EHR technology from a vendor fails when health IT is partly or fully self-developed, a commercial product version is too old to be upgraded, a hospital is in a multiyear product upgrade or conversion, or a vendor has chosen not to present an updated EHR for ONC-ATCB 2011/2012 certification.”

Questions about the program raised by industry experts include the following:

• Why spend time educating and preparing staff when you can purchase vendor-certified EHRs?

• Why commit to a lengthy certification process when personnel could be busy doing something more directly productive?

• Why risk upsetting clinicians by introducing a new layer of administrative duties and another obstacle to efficient patient care?

CCHIT officials and IT managers at EACH-certified healthcare organizations offer several reasons why it’s worthwhile to obtain the designation, most prominently that it offers a path to federal incentives without purchasing a new EHR system and without disrupting workflow.

“A lot of institutions are going out and just buying new software, and they underestimate the amount of work that’s involved in training and getting their staff used to the new system,” says Nelson Nauss, project manager for the CCHIT certification project at the University of North Carolina (UNC) Health Care System in Chapel Hill. “So sometimes it is going to be less expensive to just do the certification yourself than it is to go out and buy a new product and then have all the training you’ll have to do.”

For its part, the CCHIT provides tools to help organizations meet the criteria.

“When visiting the CCHIT-EACH website, you can see that the program is clearly explained and logically formatted,” says Alan Cudney, an executive consultant with Beacon Partners, a healthcare consulting firm. “I think there’s a critical need for this in the market because so many hospitals cannot afford to buy complete vendor-certified packages. A lot of hospitals have a combination of best-of-breed and homegrown systems that they have implemented over the years. Now, many of these organizations find that it is more difficult to achieve a smooth flow of information and level of interoperability that it will take to attest for stage 1 meaningful use.”

The Process
New York University’s Langone Medical Center, which was invited to participate in the EACH program as a pilot site, underwent the following six high-level phases to help ensure certification, according to Senior Director of IT Katie Mullaly:

• gap analysis;

• implementation of required technology changes (For example, Langone wrote a Health Level Seven International interface for public health measures, Mullaly says.);

• review of CCHIT test scripts and tools such as interoperability guides;

• practice;

• set up of EHR scenarios and preparation for inspection; and

• inspection day.

For others considering certification through the EACH program, Mullaly recommends gaining full executive support and a thorough understanding of the complete/modular EHR concept. “Create a visual diagram of the functions and applications required to meet test scripts,” she says.

Mullaly says organizations would be wise to take advantage of the available testing tools through the CCHIT. Also, interoperability requirements should be tested and a detailed gap analysis should be performed to determine readiness.

Practice, Practice, Practice
CCHIT officials and IT managers at EACH-certified hospitals insist that ample preparation is the key to success. To start, become familiar with the testing procedures of the Office of the National Coordinator for Health Information Technology and the National Institute of Standards and Technology. These criteria and procedures are accessible on the CCHIT website.

The CCHIT has developed test scripts and interpretative guidance to clarify federal criteria. Also available are the following three learning programs:

• a series of self-paced online learning programs designed to prepare EACH program applicants for testing and certification;

• an online self-assessment tool developed to help hospitals evaluate how their installed EHR technology measures up to Health and Human Services’ criteria and standards; and

• support provided by EACH program staff and access to an online community of other hospitals participating in the program.

Prior to assessment, facilities are advised to make time to practice the test steps before applying for certification.

“One of the lessons we learned—especially moving forward toward doing outpatient certification—is to team up early on with the organization you’re going to be using to go through the certification process,” Nauss says. “Especially with the EACH program, [the CCHIT is] available to answer any question, anything we’re not certain about in our interpretation of a script. Being able to tap into CCHIT early on in this process, we weren’t waiting for certification to find out whether it was right.”

At UNC, test scripts were videotaped in an effort to gain a better feel for the process, and an IT training team ran through the certification program from start to finish. Benefits accrued, both obvious and shrewd.

“It made sense to us that these are the people who go out and teach the physicians how to use the applications, so they would be the best people to actually take the test on certification day,” Nauss says. “Sometimes they’d record how to do this, and they would post that online for physicians who, instead of taking the class, could just watch the video at their convenience. It made sense to use the same recording mechanism in order to have a record of what we were planning to demonstrate on the day of inspection.”

Video recordings were also played while Web conferencing with CCHIT staff. “I would say, ‘Are we going up the right path here?’ It was great because they were able to watch what we were planning on doing and tell us, ‘Yep, this is good,’ or ‘No, you didn’t quite get this right,’” Nauss explains.

A team effort between clinical and technical staff members increases an organization’s chances for success, says Becker. “You need to be very well prepared,” she notes. “You need someone who understands the clinical processes, and then you need the technical people. We’ve developed training modules where we emphasize the fact that they need to practice the actual test scripts so that when you come for actual certification, you can know that it works. If you don’t practice what the test asks you to perform, you’re not sure exactly what’s going to happen.”

The Value of Certification
Not everyone is waving a banner in favor of EHR certification, meaningful use attestation, and the pursuit of incentive payments. Some are concerned about the administrative burden placed on physicians and staff. Beyond that, what is anyone actually gaining with EHR certification? Among its more vocal critics is Paul M. Roemer, managing partner at HealthcareITStrategy.com.

“Does the act of certification add any business value to the process? If a hospital’s productivity drops due to its EHR, does having a productivity drop make using a certified EHR of any more value?” Roemer asks. “EHR vendors and their clients can still meet meaningful use even if their productivity drops. How meaningful is that?”

The idea behind EHRs is to enhance, not diminish, effectiveness, a promise Roemer hasn’t seen fulfilled enough to back up the technology’s price tag.

“Physicians must spend more time searching, navigating, and typing,” he says. “My cardiologist who works at a prominent hospital in Philadelphia told me something memorable about their $200 million-plus EHR: ‘My productivity is down 30%. The hospital has taken its most expensive and time-constrained resource and made us spend the majority of our time interfacing with a keyboard instead of our patients.’

“Certification, to be of value, must imply that the act of certifying—like the Good Housekeeping Seal of Approval—is intended to show that a certified EHR is somehow better for healthcare than a noncertified EHR,” he continues.

The benefits at UNC have been clear, according to Nauss, who says the hospital’s EHR has had far-reaching effects as a catalyst for several projects.

“Something we’re working on right now is the implementation of [insurance] eligibility and formulary checking,” he says. “In terms of cost, it identifies if there are other medications that we could be prescribing that are similar but would cost less to our patients. So these are all things that are ultimately best in terms of patient care.”

Mulally says the cost for becoming certified under the EACH program varies according to various factors, including the number of systems being certified. In Langone’s case, the price tag was $32,550, according to Mulally, who says it was a worthwhile investment.

EACH’s Outreach
Becker says more than 100 organizations have registered to become part of the program, with 50 of those actively in the process of evaluating either complete or modular EHR certification. Meanwhile, other providers have used EACH to attack EHR certification from a different angle.

“Some organizations have used EACH to evaluate their status and then gone back to their vendors and managed to get the vendor to certify the version of software they are using,” notes Becker, adding that the CCHIT is satisfied with the program’s progress during its first year of existence.

“We have not needed to make fundamental changes to the program,” she says. “After all, we had experience on the vendor side and we had pilot organizations in both the hospital and eligible provider domains that worked with us to develop the program.”

 — Robert J. Murphy is a freelance writer based in Philadelphia.