As discussions continue about improved quality of care at more affordable cost much emphasis is being placed on health IT as a foundation for improvements in the value equation. However, with the exception of some isolated situations and delivery systems that have made large HIT investments (e.g., Veterans Health Administration and Kaiser Permanente®), we have yet to see the anticipated outcomes. Some believe it is just a matter of time, and that meaningful use of ONC certified EHRs will get us there. Others recognize that the ONC certification program in its current state will struggle to support the quality and cost agenda without further change.
The Institute of Medicine’s aims for care that is safe, effective, efficient, timely, patient-centric and equitable provide a framework for understanding the problem. As we look at how HIT might support each of these aims we see a number of themes emerge. In order for the clinician to have a system that can help provide optimal care, its functions must include some basic requirements for data integration within the system at the point of use, technical workflows aligned with clinical workflows, and easy access to comprehensive, reliable, concisely presented data. For example, an EHR must be able to easily identify and integrate discrete bits of data from e-prescribing functions, problem lists, lab results, and demographic profiles to support safe or effective care through alerts or reminders. A certification program such as ONC’s, which is designed to certify individual modules and does not include integration testing even for complete EHRs, puts these quality related aims at risk.
What does all this mean for the practicing clinician who is considering the purchase of an EHR system? Unless the clinician is adept at building or evaluating system interfaces, selection and purchase of a number of standalone ONC certified modules to meet the meaningful use requirement for certified technology may be problematic. And contracting with a third party to build the interfaces necessary to support meaningful use will be costly.
By contrast, EHR products that are dually CCHIT Certified® are tested to assure that structured data flows freely within the EHR. Diagnoses from the problem list can be added, as required, to lab test orders. Data from medication lists, allergies, vital signs, and laboratory results can be collated and used to create decision support flags when e-prescribing. Information required to generate quality measurements can also be easily assembled for calculations and reporting. In short, integration of all EHR patient care functions is a critical part of using the technology safely, effectively and efficiently. That is why CCHIT certification still requires this level of rigorous testing and site verification before certification is granted. While a provider may expect that most “complete” EHRs include this integration within their product, it is not tested nor assured by ONC certification alone.
Workflow when using an EHR is a second major issue to consider. CCHIT has independently designed, with the help of hundreds of subject matter experts, a robust set of workflow criteria that answer key questions. When in the ordering process should a drug-drug interaction be brought to the attention of the prescriber? When seeing a patient, does the system follow the usual progression of gathering and assessing information, then presenting a plan of action? Can all members of the team access the information necessary when checking on a prescription or ordering a refill? Does the system support efficient collection of all of the information gathered in a patient encounter? A comparison of the ONC certification criteria for incorporating lab results vs. those used for CCHIT certification drives this home. For ONC certification, the EHR must simply be able to take in the result with its attendant data and display it. For CCHIT certification, the EHR must also provide notification of new results, the acknowledgement of results, linkage to the original order, the capability of forwarding with comment, display on a flow sheet or in graphic format, and filtering by type and date.
Optimally, workflow should be “built in” to an integrated EHR, taking into account when in the care process key data and information can be accessed and by whom. In contrast to the CCHIT Certified® program, the ONC certification program segregates modules by their ability to support individual criteria which focus on a meaningful use measure, not clinical workflow components. This criterion by criterion focus offers no assurance that the EHR or EHR module will include or integrate all of the steps necessary to complete the clinical task at hand. Again, it becomes the practicing clinician’s responsibility to assure that an ONC certified product will help them meet patient care needs from a workflow perspective.
As we look towards Stage 2 of meaningful use with new standards, criteria and test procedures, we note that the HIT Policy Committee has made recommendations that the Clinical Decision Support measures and objectives be supported by a module that attends to workflow and is integrated within the EHR. However, unless ONC agrees that EHRs are tested as wholly integrated units as opposed to collections of individually certified modules, we will not have assurance that ONC certification processes will meet clinical need. Such an approach is unlikely since it could dramatically decrease the number of products listed as certified, dampen new product development and lead to significant market consolidation.
So…if purchasing a new ambulatory EHR to meet Stage 1 meaningful use requirements, either your first or an upgrade, consider one that is dually certified: ONC certified to provide eligibility for the Meaningful Use incentives and CCHIT Certified 2011 to assure that the product is integrated and workflows have been checked and found to be supportive of the patient care process. If interested in a product that is not CCHIT Certified, test it thoroughly by creating and using fictitious records that will address the issues of the most complicated patients you see over a period of time. Make sure that data from all fields can be imported into others. Check to make sure that all of the steps you take when the patient is in front of you are included in the workflow of the EHR in a consistent and clinically logical pattern. And if purchasing separate EHR modules, be aware that the responsibility for building and paying for the module interfaces is yours.
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.