Once the standards and criteria are finalized and published, by some estimates in September, ONC will need to publish testing procedures that must be followed when testing any of the Electronic Health Record (EHR) technologies used, so it is possible that 2014 Edition certified products won’t actually be on the market until the end of the this year. In the interim, expect a lot of public comment, especially on the following:

1. A “bulls eye” approach to EHR technology includes a number of certified functions in a Base that every provider must have, a surrounding ring of additional “Core” functions that may be setting or stage specific, and a final ring of menu functions. This approach has the definite advantage of minimizing the need to purchase technology that would not be needed or used by the clinician or hospital. It could, however, increase the risk that various modules or functions do not integrate at the patient care level and increase the need for providers to understand exactly what they need and how best to purchase it — whether they have existing technology or are newly adopting. Robust public comment is anticipated on the criteria that would be included in the Base.
2. Security has been scaled back to apply only to testing of the Base EHR and would no longer be applicable to products that support criteria in either of the two outer rings. As an example, a module that supports family health history that does not integrate with a base EHR would not be subject to any type of security testing under this proposed new rule.
3. Only one clinical quality measure would need to be tested in order for the Clinical Quality Measure (CQM) module or criterion to pass certification. Most developers, however, are likely to bring the full set for certification, though the numbers have increased in both settings.
4. Criteria that are tested together cannot be sold separately as “certified.” This is consistent with the current approach to certification. If all the certified functions in a Base EHR are certified as a unit, it must be sold as a unit. If the Base EHR meets certification by testing and certifying separate modules, the separate modules still constitute a Base, but each can be marketed and sold separately.
5. Patient safety would be addressed by vendor attestation that specified User Centric Design (UCD) principles were followed in the development process. The specific UCD principles followed by the vendor would be published. The proposal is silent on what this means for provider self built systems.
6. The proposed health IT standards will likely foster robust public comment, several of which have yet to mature to the level of specificity necessary for reliable health information exchange.
7. There are also a number of questions where ONC specifically requested public comment, such as: certification of technology for non-incentivized providers, recording of disability status, data portability, and cost transparency of certified products. Public input on these will be important as well.

There is tremendous opportunity to shape public policy and how health IT is used in health care during the public comment period and we encourage everyone to do so. The 2014 criteria and standards are available at: http://www.gpo.gov/fdsys/pkg/FR-2012-03-07/pdf/2012-4430.pdf. Public comment deadline is May 7, 2012.

CCHIT is also planning to make public comment on ONC’s NPRM on standards and criteria. We will make those comments public at the close of the public comment period in early May.

In the interim, providers with existing EHR systems must wait until the rules becomes final, the new testing procedures are developed and piloted, and the new criteria and standards are incorporated in the current 2011 Edition of certified products. These upgrades will not be necessary until FY/CY 2014 for those who already have currently certified EHR technology.

Those who are considering purchase of a new system must decide if it is better to wait for products certified to the 2014 Edition or purchase now, knowing that upgrades will be necessary before the end of 2013. When considering the choice, remember that the process of choosing a product, preparing for the transition to EHR, actual implementation, and getting used to using a system takes time — at least a year in most circumstances. Start on those parts of the journey that you can traverse now with an eye toward implementation in early 2013 if you plan to attest to Meaningful Use in the 2014 timeframe…..and choose your ONC EHR certification edition accordingly.

Karen M. Bell, MD, MMS
Chair, Certification Commission

Karen Bell, MD, MMS, is Chair of the Certification Commission for Health Information Technology (CCHIT®. Dr. Bell has wide and varied expertise in health information technology (HIT), quality assurance and clinical practice, in both the private and public sectors. Previously, she served as Senior Vice President, HIT Services, Masspro, the federally-contracted Quality Improvement Organization within Massachusetts, where she oversaw the development, implementation and distribution of products and services to support adoption of electronic health records (EHRs) within the health care system. Between 2005 and 2008, Dr. Bell was Director, Office of Health Information Technology Adoption, Office of the National Coordinator (ONC), U.S. Department of Health and Human Services (HHS), and, in 2006, served as Acting Deputy of ONC. She was ONC’s representative on CCHIT’s Board of Commissioners from 2006 to 2008.

Prior appointments held by Dr. Bell include Division Director, Quality Improvement Group/Office of Standards and Quality for the Centers for Medicare and Medicaid (CMS), and Medical Director of Blue Cross Blue Shield (BCBS) of Rhode Island and of Anthem BCBS of Maine.

She received her medical degree from Tufts University School of Medicine, Boston, and her master of medical science degree from Brown University, Providence, R.I. Dr. Bell has clinical experience as a board certified physician in internal medicine and also was an Associate Professor at the University of Rochester, and Clinical Instructor at Harvard University School of Medicine.

In the interim, physicians and other clinicians as well as hospitals are finding the proposed new rules to be complex, confusing and not necessarily consistent with their own timeframes for adopting ONC certified technology and meeting meaningful use goals. However, decisions about purchasing and implementing technology or what stage to attest to and when may need to be made well before the new technologies are ready and new reporting periods begin.

One of the salient points to be made about both proposed rules is that extensive public comment was requested, extensive public comment is expected, and it is possible that aspects of both rules could be scaled back. Since public comment is required when making these rules, the Federal government cannot add elements in a final rule that have not had public scrutiny. They can, and generally do, however, propose “stretch” goals — measures, requirements and criteria that might be modified, based on public comment. Therefore, much of the new material could undergo change — some of it significant — making it unwise to bet on any of it at this point.

CMS’s NPRM on Stage Two can be summarized as follows:

1. Most of the changes from Stage One to Stage Two Meaningful use involve:
   • Increasing the percent threshold of an existing measure (e.g., from 50% to 80%)
   • Moving a measure from “menu” to “core (e.g., conduct medication reconciliation for transitions of care to an Emergency Department or a hospital to an eligible provider)
   • Extending current reporting requirements (e.g., require continuous reporting of public health indices rather than a single demonstrate that they can be done)
   • Requiring use of structured data to enter information that could have been entered as free text or other indication in Stage One

    
   With the exception of developing workflows for continuous reporting of public health data, these represent no or minor changes from Stage One. You could possibly see them in the final rule with little or no change from what was proposed.

 

2. Five of the new measures are in the menu set and include successful ongoing submission of cancer case information to a cancer registry and to a second specialized registry for eligible professionals; e-prescribing of discharge medications for hospitals; and access to images and structured data entry of family history information for both sets of providers.
    
   Successful ongoing submission of data to registries assumes that there will be registries which are programmed to accept these data, though they are not mentioned in the proposed rule. It also assumes supportive workflow for this process within the clinical setting. Public comment on these new menu measures could be pivotal.

 

3. As new core measures, hospitals would now use e-Medication Administration Record systems, patients of eligible professionals would use secure messaging, and both hospitals and clinicians would attest that more than 10% of their patients actually viewed, downloaded, and transmitted their health information electronically to a third party , such as a patient controlled health record or another provider. Lastly, 10% of transition of care summaries would be sent to unrelated EHRs outside of both provider types’ organizational affiliation.
    
   Expect significant comment on these new proposed core measures that depend on patients’ desire and ability to perform the defined task, some assurance that information transferred by a provider to a “third party” is to a secure environment, and probable disruption of established referral patterns either within or external to an accountable care environment.

 

4. Additional quality measures: 12 total for eligible providers (group reporting allowable) and 24 Continuous Quality Measures (CQMs) for hospitals (includes 15 from Stage One)
    
   Anticipate public comment on need to align measures across programs and need for development of robust and reliable e-measures.

 
ONC’s NPRM on Standards and Certification Criteria had far more modifications than the Meaningful Use NPRM. These will be reviewed in detail in Part 2, with the recognition that the final standards and certification rule must be aligned with the final rule for Stage Two Meaningful Use objectives and measures. Part 2 will appear in April’s edition of Letter from Chair. CCHIT is also planning to make public comment on ONC’s NPRM on standards and criteria. We will make those comments public at the close of the public comment period in early May. We encourage our readers to review these NPRMs and make their own comment. The Stage Two Meaningful Use objectives and measures. Public comment deadline is May 7, 2012.

Karen M. Bell, MD, MMS
Chair, Certification Commission

Karen Bell, MD, MMS, is Chair of the Certification Commission for Health Information Technology (CCHIT®. Dr. Bell has wide and varied expertise in health information technology (HIT), quality assurance and clinical practice, in both the private and public sectors. Previously, she served as Senior Vice President, HIT Services, Masspro, the federally-contracted Quality Improvement Organization within Massachusetts, where she oversaw the development, implementation and distribution of products and services to support adoption of electronic health records (EHRs) within the health care system. Between 2005 and 2008, Dr. Bell was Director, Office of Health Information Technology Adoption, Office of the National Coordinator (ONC), U.S. Department of Health and Human Services (HHS), and, in 2006, served as Acting Deputy of ONC. She was ONC’s representative on CCHIT’s Board of Commissioners from 2006 to 2008.

Prior appointments held by Dr. Bell include Division Director, Quality Improvement Group/Office of Standards and Quality for the Centers for Medicare and Medicaid (CMS), and Medical Director of Blue Cross Blue Shield (BCBS) of Rhode Island and of Anthem BCBS of Maine.

She received her medical degree from Tufts University School of Medicine, Boston, and her master of medical science degree from Brown University, Providence, R.I. Dr. Bell has clinical experience as a board certified physician in internal medicine and also was an Associate Professor at the University of Rochester, and Clinical Instructor at Harvard University School of Medicine.

With so many certified products, providers are overwhelmed and confused looking for products that meet their particular practice needs, best support patient care, and also garner incentive payments, experts said.

“We feel quite strongly that clinicians should know more about what technology they are purchasing,” said CCHIT Chairman Karen Bell.

As the Office of the National Coordinator for Health Information Technology’s EHR certification program moves forward in Stages 2 and 3 of meaningful use incentive program, EHR modules, systems, and other health information technologies will consolidate and give providers fewer choices for certified products, Harry Greenspun, senior advisor for health care transformation and technology at the Deloitte Center for Health Solutions in Washington, told Bloomberg BNA.

“I think we will continue to see consolidation of the market, … also consolidation more broadly in terms of physician practices, hospitals, and movement toward accountable care,” he said.

For more, visit Bloomberg BNA Health Law Resource Center.

The first publication of some significance became available in January 2012 — the list of products used by providers who have successfully attested to meaningful use of certified EHRs in the first year of the Medicare incentive program. Each month at the HIT Standards and the HIT Policy Committees, we learn the numbers of providers registered in both the Medicare and Medicaid meaningful use programs, as well as the numbers of providers that have received incentive payments. The latter numbers are still small (4.4% of all eligible clinicians) but it is likely that they will grow as more successful attesters receive their payments. While we know little about these successful attesters due to their relatively small numbers, we now know what technologies these clinicians are using. And it’s no surprise that the vast majority are using tried-and-true EHRs of multiple varieties — both server-based and web- based.

This finding may be related to the staggering number of choices on ONC’s Certified HIT Product List (CHPL), which currently includes more than 1,100 ambulatory products. Some are minor version changes of the same product and many are “modules” — technologies that meet one or more meaningful use criteria to complement other products that are not complete EHRs. Given its sheer volume, the list is overwhelming and confusing to clinicians looking for products that meet their particular practice needs, best support patient care, and also garner those incentive payments. The obvious fall back is for the clinician to choose what has been demonstrated to work in the clinical environment by others over the years.

The heavy dependence on the familiar names and products also could be because most of the attesters already had and were comfortably using EHRs before ARRA/HITECH was enacted. With an upgrade to assure that their EHRs could be certified for meaningful use and greater attention to measurement and reporting, these earlier adopters could be among the first to complete the application and attestation processes and see a check appear in the mail for these within a few months.

The most important reason for the reliance of these first attesters on well known systems, however, may very well be that these products are the ones that best meet clinicians’ need for information support as they care for their patients. It should be no surprise, then, that more than two-thirds (68%) of the complete EHRs listed are also CCHIT Certified®. These are the products that have been tested for integration of function, workflow, and state of the art security with the clinician and patient in mind — far beyond what ONC certification requires for Stage One meaningful use measurement. Since CCHIT does not have certification programs for many of the specialty EHRs listed — such as products used only by chiropractors, optometrists, or podiatrists — the reliance on dually certified products, CCHIT Certified ® and ONC Certified in the general medical community is even more striking. Most clinicians want the assurance that patient data will be backed up (not lost), that information is integrated within their system (instead of needing a degree in medical informatics or paying large sums to integrate disparate modules), that the systems have been demonstrated to work in an office environment similar to their own (with minimal risk of the vendor withdrawing from the market), and that the EHR has met at least a basic test for usability.

It’s also important to recognize that all of these attributes are basic patient safety features in an EHR system. There is no question that innovation is good for all concerned…even the best of EHRs today have their flaws. Innovation, however, carries varying degrees of risk. When that risk can lead to patient safety problems, clinicians tend to become relatively risk adverse and rely on what is familiar and proven to work. Does this mean we will be relying on the current EHR base in the future? Highly doubtful. We will eventually get to plug-and-play systems where a provider can choose among various medication management vendors, various vendors’ closed loop order entry systems, and various disease registry systems vendors that all integrate on a single platform. But that’s the future, and not within the time span of the current meaningful use incentive program. So, for now, look for more of the same — a heavy reliance on tried-and-true CCHIT Certified® EHRs that also are ONC Certified.

Karen M. Bell, MD, MMS
Chair, Certification Commission

Karen Bell, MD, MMS, is Chair of the Certification Commission for Health Information Technology (CCHIT®. Dr. Bell has wide and varied expertise in health information technology (HIT), quality assurance and clinical practice, in both the private and public sectors. Previously, she served as Senior Vice President, HIT Services, Masspro, the federally-contracted Quality Improvement Organization within Massachusetts, where she oversaw the development, implementation and distribution of products and services to support adoption of electronic health records (EHRs) within the health care system. Between 2005 and 2008, Dr. Bell was Director, Office of Health Information Technology Adoption, Office of the National Coordinator (ONC), U.S. Department of Health and Human Services (HHS), and, in 2006, served as Acting Deputy of ONC. She was ONC’s representative on CCHIT’s Board of Commissioners from 2006 to 2008.

Prior appointments held by Dr. Bell include Division Director, Quality Improvement Group/Office of Standards and Quality for the Centers for Medicare and Medicaid (CMS), and Medical Director of Blue Cross Blue Shield (BCBS) of Rhode Island and of Anthem BCBS of Maine.

She received her medical degree from Tufts University School of Medicine, Boston, and her master of medical science degree from Brown University, Providence, R.I. Dr. Bell has clinical experience as a board certified physician in internal medicine and also was an Associate Professor at the University of Rochester, and Clinical Instructor at Harvard University School of Medicine.

One of the recommendations gave the Department of Health and Human Services 12 months to contribute to and assess progress in the public and private sectors towards these efforts, after which time the report recommended that the Secretary should make determination regarding the necessity for Food and Drug Administration regulation. If not necessary at that time, the Secretary should reassess this decision on an annual basis.

As these recommendations are considered and variously implemented the question remains on clinicians’ minds as to how they can assess whether or not their own electronic health record (EHR) supports safe care now to the greatest extent possible. While there is no one tool that can be applied to answer that question, there are practical approaches that could be used to assure that the most up-to-date functions and features are present.

A good place to start is malpractice claims.  52% of all paid medical malpractice claims in 2009 were in the ambulatory setting, with two thirds of these involving major injury or death. A recent analysis suggests that most adverse judgments fall into three categories: poor communication, poor documentation, and problems associated with diagnosis and treatment of a patient. It’s worth considering how health IT can better address these issues, and the degree to which they can currently be assessed to do so.

Communication gaps can occur within a practice, among clinicians in different locations, and between clinicians and patients. Does your system allow secure messaging with patients; does it have a patient portal through which you can communicate with your patients? Can you generate and record patient specific instructions as well as educational materials. Does your EHR support concurrent use by multiple staff and can you access, create, and allow modification of jointly managed care plans? What about clinical task assignments and routing, and the ability to co-sign notes? Are verbal, telephone, and electronic messages between users documented, along with discrete data on specified roles of each provider associated with a single patient? Recognizing that interoperability with external provider systems is beyond the scope of a single EHR, do you at least have a directory of external providers and can you capture external documents?

Documentation is the second major area to consider. Does your system support efficient but reliable documentation of your findings and results? Can you incorporate free text? Do your checklists and templates appropriately default to normal findings only when you have actually examined the patient and recorded your positive findings, including those areas not examined? Can you make modifications and corrections? Are consents and authorizations clear and easily retrieved?  How easily and accurately can you manage problem lists, medication lists, and allergy and adverse reaction list as well as clinical documents and notes? As alerts and reminders are brought to your attention, is there some way to document why you may or may not choose to act on them? Lastly, check for back up.  A system that can lose patient data is one with a built in patient safety risk.

Diagnosis and treatment risks can be mitigated to a large extent by good e-prescribing, medication management, and medication reconciliation functions. Alerts should optimally include drug/drug, drug/allergy, drug/diagnoses, and some form of drug/lab information, but should be meaningful to the individual clinician using the system to avoid alert fatigue.  Another area where an EHR can help mitigate patient safety risk is closed loop ordering. This means that the clinician should at least be able to view active orders for a patient, display outstanding orders for multiple patients, see the status of orders, receive notification when new results are received, and link results to the original order. It also means that the clinician is notified when a test result is not returned, or a prescription has not been filled, though few systems function at that level now.  Ways of assuring that patients receive appropriate testing for disease management, medication management, and preventive services should include both reminders inserted into clinical workflows and automatic reminders to patients or their guardians.  The last, and arguably the most important areas in support of appropriate diagnosis and treatment are data integration and presentation. Are you informed whenever new data points enter your patients’ records? Can you easily eliminate or modify duplicative or erroneous data points?  How well does your system aggregate data and present them in usable formats so that you are truly knowledgeable about your patients’ history and progress?

All three areas interdigitate. Good communication requires good documentation requires good data management requires good communication. As CCHIT certification has matured over the years, attention has been paid in all three areas with the recognition that integration of all functions is the foundation on which all other patient safety functions rest. Testing for integration using clinical workflows that support many of the patient safety functions listed here is unique to CCHIT Certified® products, and is not present in ONC certification, as many of the functions are not. As we look to the future, CCHIT will increase its focus on assuring that patient and provider needs for safer, more usable systems are met.

Karen M. Bell, MD, MMS
Chair, Certification Commission

Karen Bell, MD, MMS, is Chair of the Certification Commission for Health Information Technology (CCHIT®. Dr. Bell has wide and varied expertise in health information technology (HIT), quality assurance and clinical practice, in both the private and public sectors. Previously, she served as Senior Vice President, HIT Services, Masspro, the federally-contracted Quality Improvement Organization within Massachusetts, where she oversaw the development, implementation and distribution of products and services to support adoption of electronic health records (EHRs) within the health care system. Between 2005 and 2008, Dr. Bell was Director, Office of Health Information Technology Adoption, Office of the National Coordinator (ONC), U.S. Department of Health and Human Services (HHS), and, in 2006, served as Acting Deputy of ONC. She was ONC’s representative on CCHIT’s Board of Commissioners from 2006 to 2008.

Prior appointments held by Dr. Bell include Division Director, Quality Improvement Group/Office of Standards and Quality for the Centers for Medicare and Medicaid (CMS), and Medical Director of Blue Cross Blue Shield (BCBS) of Rhode Island and of Anthem BCBS of Maine.

She received her medical degree from Tufts University School of Medicine, Boston, and her master of medical science degree from Brown University, Providence, R.I. Dr. Bell has clinical experience as a board certified physician in internal medicine and also was an Associate Professor at the University of Rochester, and Clinical Instructor at Harvard University School of Medicine.

If you think about certification, I’ll divide into two phases. One is the formation of CCHIT, which was to help increase adoption of health information technology by removing some of the risk on the buying side, and that CCHIT certification really meant something and that when if you were buying a CCHIT-certified product, it wasn’t going to be perfect, but you could be assured it was going to have some baseline interoperability security and functionality.

I do think that that changed very much the way that people purchased systems. For example, the days of the scripted demos to make sure that you could do long lists of specific feature-function .. those days are gone, and mostly because if it’s a CCHIT-certified product, you can already pull out the long list of feature-function, security, interoperability items that you know the product can do. I really believe very strongly in CCHIT moving the market forward.

Read more of the interview. Or for more insights from Dr. Byrne, visit her blog.

This type of information sharing among various types of providers using disparate EHRs is critical for true care coordination.   Also important, however, is the degree to which clinicians and EHRs in the ambulatory setting are prepared to actively provide more comprehensive integrated care as more robust data become available.   There are a number of basic functions that are common to most EHRs (i.e., recording patient demographics, drug/drug alerts, reminders, report generation, etc.).   There are also a number of integrated EHR functions that are key to the support of care coordination by practices.

Support team-based care

As you reassess your current EHR or look to a new one, there are a number of care coordination functions you should look for.  A good starting point would be to support team-based care through EHR use of:

• Intra-practice communications  through messaging, inclusion of verbal orders, and recording of telephone conversations
• Concurrent use of your EHR by multiple authorized individuals while maintaining information integrity when accessing care plans, guidelines, and protocols
• Clinical task assignment and routing
• Management of clinical documents and notes to include co-signers, corrections, support for both  notes in progress and  final notes, patient annotations, and free text in addition to structured data

Organize and assess

Once you have built an effective team with clear job descriptions and efficient workflows, and you have trained them well to use these enabling functions, you will want to assure that you have an EHR with the functionality necessary to organize and assess your electronic patient health information.   Some of the more important areas that you should look for are:

• Managing coded problem lists to include not just diagnoses, but dates of onset, resolution, chronicity, updates, linkage to orders, addition of free text, and different ways of viewing
• Managing medication lists to include ordering clinician, changes (when and who made them) explanatory free text, medication history, over the counter preparations, or  no medications when that  is the case
• Managing results — in addition to many of the steps noted above, you will want your EHR to be able to display results graphically and on flow sheets, be notified of new results, and forward results to others with notes and annotations
• Managing a patient history by including documents from external sources, recording both negative and positive findings, and updating clinical, family, and social histories

Consider patient engagement

Care coordination without patient engagement is an oxymoron.   You will want to know your EHR system at least supports:

• Generating and providing patient specific instructions through links to other sites or from embedded functionality
• Managing  consents and authorizations with the ability to print, sign, and store and possibly allow for electronic patient signature
• Managing  advanced directives by at least noting the type, that you’ve reviewed them with the patient, and where they might be found or who should be contacted as a health care proxy
• Identifying  all clinicians engaged in a specific encounter and the primary provider of care
• Scheduling of appointments and follow-ups, and the ability to view whether or not they were kept

If your system provides a patient portal or secure messaging with a patient, consider this an added but important bonus.

Incorporate data electronically

Lastly, until your capacity to incorporate data electronically from other sources expands, you will want your EHR to support some way of

• Capturing, storing, and indexing external clinical documents
• E-prescribing and communicating with pharmacies about medication requiring prior authorization or other administrative processes

Conclusion

In summary, you can review your EHR and processes now to assure that you are coordinating care for your patients using the information you currently have.   When access to more comprehensive patient data from outside of your office setting or healthcare system becomes available, they can be incorporated into the record and be included in your approach to the coordinated care that you already have in place.

Many of these desirable functions are already included in EHRs tested by our CCHIT Certified® 2011 program. This independently developed CCHIT certification program includes a more rigorous inspection of integrated EHR functionality than the Office of the National Coordinator (ONC) authorized program which is designed only to meet minimum government requirements qualifying providers for meaningful use incentives. Future CCHIT Certified development will continue to consider the evolving care coordination needs of office-based practices.

Karen M. Bell, MD, MMS
Chair, Certification Commission

Karen Bell, MD, MMS, is Chair of the Certification Commission for Health Information Technology (CCHIT®. Dr. Bell has wide and varied expertise in health information technology (HIT), quality assurance and clinical practice, in both the private and public sectors. Previously, she served as Senior Vice President, HIT Services, Masspro, the federally-contracted Quality Improvement Organization within Massachusetts, where she oversaw the development, implementation and distribution of products and services to support adoption of electronic health records (EHRs) within the health care system. Between 2005 and 2008, Dr. Bell was Director, Office of Health Information Technology Adoption, Office of the National Coordinator (ONC), U.S. Department of Health and Human Services (HHS), and, in 2006, served as Acting Deputy of ONC. She was ONC’s representative on CCHIT’s Board of Commissioners from 2006 to 2008.

Prior appointments held by Dr. Bell include Division Director, Quality Improvement Group/Office of Standards and Quality for the Centers for Medicare and Medicaid (CMS), and Medical Director of Blue Cross Blue Shield (BCBS) of Rhode Island and of Anthem BCBS of Maine.

She received her medical degree from Tufts University School of Medicine, Boston, and her master of medical science degree from Brown University, Providence, R.I. Dr. Bell has clinical experience as a board certified physician in internal medicine and also was an Associate Professor at the University of Rochester, and Clinical Instructor at Harvard University School of Medicine.

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.

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.”

For more, visit For the Record.

Still, this is a major transition in your life and in your practice. And, like many other major transitions that you plan and prepare for, “go live” is more complicated than you may think–and fraught with a number of challenges.

One thing that can help is talking to people who have lived through this transition. Clinicians who have been through the process and those who provide help and support to those clinicians can offer some practical advice, starting with the need for thorough training before transition date. Hopefully your vendor has supplied you with a number of training modules that you and each of your staff have mastered. If not, ask for a list.

You will have spent time undergoing a full self-assessment of your practice patterns and preferences so that you can identify and prioritize those functions that are critical for patient care at the time of installation and those that you may choose to implement in the near future. As a practice, you need to have come to agreement on what will be abstracted from the paper record, how the information will be entered into the EHR, who will accomplish this time-consuming task and what the timeline for completion looks like. You will need to be facile with the use of data migration templates. Your team will have completed all of the policies and procedures necessary to input new information on a specific number of both established and new patients before go-live. You will be familiar with the building of order sets, favorite lists and coding guidelines. But, you should also keep meaningful use and quality measures in mind during the pre-go live decision-making and preparation. Don’t underestimate the importance of your entire staffs’ involvement in this pre-go live planning, decision-making and workflow redesign to the success of your EHR implementation.

You will have learned how to build and populate templates for the most common problems that you see clinically, so that these templates can be implemented and test driven before go-live. The same is true with alerts and reminders. If you have a patient portal with your EHR, you will have developed policies and procedures concerning patient consent and what information patients will be able to access and when. Likewise, you will need to work with your vendor to assure that you are appropriately set up to maintain those policies while allowing promised access of information to your patients.

Perhaps one of the most important things to consider is how your clinical and billing functions integrate. Make sure that on “go live” day that all of your payers are included in the system, that all billable care is captured and reported, and that an appropriate claim is successfully submitted to the appropriate payer.

Lastly, don’t assume that you can do everything on go-live day. Good implementations take time and further training, ongoing workflow adjustments and software updating will be needed. Problems will arise. It just happens. Make sure the most important aspects of the EHR are installed, functioning well, and understood by all members of your practice staff by the end of the “go live”, but also make sure that you have your vendor’s commitment to return several times more to help you add more functions, expand more in depth the ones you started with, or make necessary modifications as you discover what works and what doesn’t. A good vendor is a good partner throughout the entire transition period, not just on go-live day.

Karen M. Bell, MD, MMS
Chair, Certification Commission

Karen Bell, MD, MMS, is Chair of the Certification Commission for Health Information Technology (CCHIT®. Dr. Bell has wide and varied expertise in health information technology (HIT), quality assurance and clinical practice, in both the private and public sectors. Previously, she served as Senior Vice President, HIT Services, Masspro, the federally-contracted Quality Improvement Organization within Massachusetts, where she oversaw the development, implementation and distribution of products and services to support adoption of electronic health records (EHRs) within the health care system. Between 2005 and 2008, Dr. Bell was Director, Office of Health Information Technology Adoption, Office of the National Coordinator (ONC), U.S. Department of Health and Human Services (HHS), and, in 2006, served as Acting Deputy of ONC. She was ONC’s representative on CCHIT’s Board of Commissioners from 2006 to 2008.

Prior appointments held by Dr. Bell include Division Director, Quality Improvement Group/Office of Standards and Quality for the Centers for Medicare and Medicaid (CMS), and Medical Director of Blue Cross Blue Shield (BCBS) of Rhode Island and of Anthem BCBS of Maine.

She received her medical degree from Tufts University School of Medicine, Boston, and her master of medical science degree from Brown University, Providence, R.I. Dr. Bell has clinical experience as a board certified physician in internal medicine and also was an Associate Professor at the University of Rochester, and Clinical Instructor at Harvard University School of Medicine.

Berger said the homegrown system is somewhat unique and has served UNC well. “We were perfect to do the EACH certification,” he said. With some of our system commercial and some homegrown, we didn’t want to rip everything out and start all over.” Berger estimated the cost of starting over at somewhere near $300 million.

For more, read the article from Healthcare IT News.