Jeff Soble, Neil Cowles, and Edmund Billings have a response reproduced after the break to HIMSS “Call to Action”. This is a sobering look at the American Recovery and Reinvestment Act of 2009 which looks poised to result in the demise of real competition, medical data in the hands of a cartel or monopoly for a few wealthy corporations, loss of privacy and the loss of the physician as the traditional custodian of medical data. Item 3 is salient: “CCHIT works to the benefit of a small number of large EMR vendors that can command a high price from the relatively small segment of the market able to currently afford their products. It is essentially anti-competitive, and establishes a major barrier to entry by new vendors and open source projects (where the majority of innovation will take place).”
Response to HIMSS “Call to Action”
HIMSS recently published recommendations to the Obama administration and the 111th Congress that include worthwhile goals and initiatives to promote adoption of health reform through information technology:
http://www.himss.org/ASP/ContentRedirector.asp?ContentId=68724&type=HIMSSNewsItem
However, while its aims are laudable and many of the recommendations are appropriate, HIMSS is mistaken in calling for restricting federal funding and incentives for the adoption of health IT (including expansion of Stark exemptions and anti-kickback safe harbors) to products certified by the existing CCHIT process. An alternative set of recommendations would preserve and promote HIT choice, competition and innovation, and better serve the public interest:
1) A government or government-sponsored organization should develop a health information technology data interchange certification program.
a) Data interchange certification could be included in, but should not depend on, certification for more general EMR/EHR specifications or functional requirements.
b) Data interchange certification should be built on existing data interchange standards and initiatives (HL7, DICOM, IHE, HITSP).
2) Any federal funding, endorsement, or extension of Stark exemptions for HIT systems should be based only on data interchange certification.
The rationale for this position includes:
1) The central problem with existing HIT systems is lack of interoperability, not the absence of any specific functionality.
2) The 2009 report of the National Research Council on HIT identified a significant gap in ROI from investments in existing systems. One of its primary recommendations for the federal government was to encourage initiatives to empower iterative process improvement and small-scale optimization.
In addition, a 2008 NEJM study makes clear that the number one issue impeding adoption of ambulatory IT systems is cost, with only 4% of practices having a fully-implemented EMR.
The solution to this problem is not to throw funding at expensive monolithic software that promotes vendor lock-in, but to foster the development of flexible, affordable and interchangeable solutions. This means fostering interoperable components (both proprietary and open-source) that can be right-sized to the needs of specific healthcare environments, rather than promoting one-size-fits all systems.
3) As it currently exists, CCHIT certification is an inappropriate standard for federal funding, authorization or endorsement of HIT systems:
a) CCHIT 2009 certification has over 450 separate requirements, the collective effect of which tremendously increases the cost and complexity of IT solutions. Many of these requirements are “functional specifications” that should be determined by customer needs and priorities, rather than by committee. These requirements foster (if not mandate) the development of rigid, monolithic systems.
b) The monolithic approach to certification taken by CCHIT does not reflect the current advances in information technology being leveraged by other industries where integrated solutions are used to support the complete “end-to-end” business process. Integration and interoperability are essential to leverage the potential of “cloud computing” and other service orientated delivery mechanisms.
c) CCHIT works to the benefit of a small number of large EMR vendors that can command a high price from the relatively small segment of the market able to currently afford their products. It is essentially anti-competitive, and establishes a major barrier to entry by new vendors and open source projects (where the majority of innovation will take place).
d) A quick count from the CCHIT website gives the following results for the number of systems certified for ambulatory EMR (including conditional certifications and multiple certified products from a single vendor):
i) 2006 = 93
ii) 2007 = 55
iii) 2008 = 14
At this rate of attrition, the number of certified products will dwindle to the single digits.
e) The shrinking number of vendors that are capable of meeting CCHIT certification exposes a fundamental flaw in its current organizational structure – CCHIT is funded by the very vendors it certifies. In order for it to maintain revenue, it needs to provide a reason for vendors to continue to either:
i) re-certify on a regular basis
ii) apply for new certifications
The problem with this model is that, in order to justify ongoing re-certification, CCHIT must continue to add new certification requirements year-to-year. The driver for more requirements is not necessarily the needs of customers or the best interest of the healthcare system, but the need to have new requirements against which to certify vendors. This is illustrated by the fact that CCHIT has recently reduced the length of the certification from three to two years, and is adding numerous supplemental certifications in areas like child health, cardiovascular, etc. There is no end to the number of requirements to which this could lead, but there is no evidence it will serve anyone well in the long run, other than the few large vendors with the resources to keep up with this process, and CCHIT itself.
f) Although in theory vendors can apply jointly for CCHIT certification, in practice the monolithic certification process will limit the ability for vendors to provide component solutions from which customers can choose to create best-of-breed, low cost solutions that best fit their needs. For instance, in the ambulatory arena, this might typically be a combination of Practice Management, EMR and e-Prescribing solutions.
g) Certification of Practice Management systems in other markets (e.g., UK) has arguably reduced innovation and investment, increased the total cost of ownership and consolidated the market to such a point that there is limited choice and the barrier to entry for new entrants into the marketplace is unaffordable.
4) A separate data interchange certification program would not prohibit HIT consumers from using other CCHIT certifications on a voluntary basis to guide purchasing decisions where they see fit.