Should CCHIT Influence Your EHR Selection?

In 2010 the Certification Commission for Healthcare Information Technology – CCHIT – became an ONC Authorized Testing and Certification Body or ONC-ATCB. They are one of six organizations that can certify electronic health records to support "meaningful use" criteria outlined in the Stimulus Bill (for more information, read The Stimulus Bill and Meaningful Use of Qualified EHRs / EMRs). To learn more about ONC-ATCB certified EHRs, visit our buyer's guide or view a free demonstration of these popular systems:

The CCHIT has gained substantial momentum since the organization's founding in 2004. As a result, buyers of electronic health records (EHRs) – or electronic medical records (EMRs), as they are also known – often ask me what role CCHIT certification should play in their purchase decision. The answer is not always simple, so I decided to explain what CCHIT is, what it is not, and why some participants have passionate views for or against it.

What is CCHIT?
CCHIT is a private, non-profit organization formed to certify EHRs against a minimum set of requirements for functionality, interoperability and security. It was founded in 2004 by three industry associations (HIMSS, AHIMA and the Alliance). It was subsequently funded further by the California Healthcare Foundation and a group of payers (e.g. United HealthGroup), providers (e.g. HCA) and software vendors (e.g. McKesson). In 2005, CCHIT was granted a $2.7 million contract by the Department of Health and Human Services (HHS) to support its mission. A number of other medical associations have since supported CCHIT. Despite the HHS contract, CCHIT is not an extension of the federal government.

As of March 2009, Eighty-some ambulatory EHRs received certification against the 2006 CCHIT criteria, sixteen EHRs received certification against the more rigorous 2007 criteria and twenty have achieved CCHIT certification for the 2008 Ambulatory EHR criteria. We estimate this equates to roughly 30% of all ambulatory EHRs being certified, while additional EHR vendors are currently pursuing certification for their systems.

Visit this page for a list of CCHIT certified EMRs / EHRs.

What are the benefits of CCHIT?
CCHIT is performing an important role in defining EHR functionality and promoting standards for EHR interoperability and security. While most healthcare participants agree that moving medical records to an electronic format is important, there is little consensus on what should constitute an EHR and how those systems should securely share data. The problem is complicated by the large number of EHR products (~300), an unending barrage of marketing claims and the unfortunate reality that many EHR implementations fail.

CCHIT has taken on the task of defining the key functional components of an EHR, how it should communicate with other systems and how it should protect patient information. The CCHIT criteria consist of a list of detailed product capabilities against which EHRs are evaluated. At the very least, CCHIT has created a functional requirements checklist for EHR buyers. Adopted in full, CCHIT has provided buyers with a list of EHRs that meet every one of these requirements.

Why does CCHIT generate some controversy?
As CCHIT gains momentum, many EHR buyers are using its certification as a filtering mechanism for which EHR products to include in their selection process. Moreover, many payers, associations and healthcare information exchanges (HIEs) are also mandating CCHIT certification in various ways. This, of course, is CCHIT's intended role. Software vendors that are CCHIT Certified® like this trend because it is more likely their products will be included in those purchase decisions. Non-certified vendors hate it because it eliminates them from those opportunities, even if their product could have been a good fit for the provider. The most intense detractors have labeled the organization an anti-competitive “cartel” that forces small vendors out of the market. We don't support the cartel allegation, but we also don't downplay the impact that CCHIT is having on the EHR competitive environment. Both supporters and detractors of CCHIT make logical arguments as to what role CCHIT certification should play in EHR selection processes.

Why doesn't every vendor just get certified?
It's not that easy. Many non-certified vendors object to the certification fees – $29,000 for the initial review and $6,000 in annual maintenance fees over the three-year certification. CCHIT charges those fees to support its twenty-person staff and compensate the jurors that perform the EHR product reviews. In our opinion, the fees are not nearly as significant as the cost of developing the CCHIT-required product capabilities. The cost of developing some features could cost hundreds of thousands of dollars a year, depending on the effectiveness of the vendor's development team and the extensibility of the underlying software code. This is often a more acute issue for vendors that sell at a lower price point. For example, many vendors have a deliberate strategy to offer a lightweight, easy-to-use EHR for simple SOAP notes and patient records. While that type of product offering would meet demand from a large segment of the ambulatory market, it would not meet the broad set of functional requirements set forth by CCHIT. It's particularly frustrating to these vendors if their customers are not asking for every one of the capabilities that CCHIT requires.

What are the criteria used by CCHIT to certify EHRs?
As of March 2009, CCHIT certifies EHRs based on about 475 criteria spanning EHR functionality, interoperability and security. These criteria start with basic functions like managing a patient record, patient history and clinical notes. However, they expand on those basic features by requiring more advanced functions like pharmacy and laboratory integration. These are great capabilities that could improve provider efficiency and patient care if adopted effectively. However, does every physician need and want them? No, not everyone. Nevertheless, if an EHR product does not have every CCHIT-required capability, it will not be certified; that is, CCHIT is all or nothing. Every criterion must be met for an EHR to achieve certification. There is no partial or feature-by-feature certification.

What important criteria does CCHIT not evaluate?
As just noted, CCHIT certifies EHRs based on criteria for functionality, interoperability and security. At this point, CCHIT does not evaluate:

• ease-of-use of EHR software products;
• financially viability of the company offering the EHR software; or,
• the quality of customer support offered by the software vendor.

CCHIT makes all of these exclusions very clear in their 2007 Physician's Guide:

One thing hasn't changed, and that's the necessity of your doing some pre-purchase homework. While [CCHIT] certification evaluates the EHR product, learning about the company behind the product is an essential part of the purchasing process and remains your responsibility.

Does CCHIT evaluate specialty EHRs or templates for specialists?
Another important element of EHR selection is the product's ability to support specialties with unique EHR requirements. At present, CCHIT offers optional certifications for cardiovascular medicine, child health, inpatient and emergency department EHRs. In 2009, the organization will evaluate behavioral health EHRs, develop criteria for certifying HIEs and delve into other technologies including personal health records and electronic prescribing. It will take some time before CCHIT is capable of evaluating the full range of specialty EHRs or specialty templates.

We think this is especially important given that many specialty EHRs are developed by smaller vendors. Their addressable market opportunity is smaller, their development budgets are smaller and their product development prioritizes features required by the specialty. For example, a solo obstetrician will certainly be focused on how an EHR manages ante-partum visits, but may not be focused on a requirement for the system to support multiple physicians. CCHIT does not assess ante-partum templates, but it does require multi-physician support.

Will CCHIT result in higher prices for EHRs?
Critics often contend that CCHIT certification will lead to higher EHR prices because: 1) vendors will have to pass on the cost of certification and new feature development; and, 2) certification will limit competition by narrowing the number of competitive software vendors.

Regarding the first point, we think it is unlikely that vendors seeking CCHIT certification will be able to pass on their expenses to their customers. The market is simply too competitive. Instead, the vendors will likely bear the cost themselves in the form of lower profit margins. Non-certified EHRs may even have to lower their prices to remain competitive.

As for the second point, one hundred EHR vendors should be more than enough suppliers to ensure price competition. However, many of the current CCHIT Certified EHRs have traditionally been the more expensive products, in large part because they offer more features. If you want a CCHIT Certified EHR today, you may pay more. Over time, as more vendors build out CCHIT's required capabilities, products will gain functional parity and price competition will likely ensue.

Where CCHIT will affect pricing is if it leads to the elimination of low-cost or open source (i.e. free) EHR products that can't afford to clear the CCHIT hurdle. A low-cost provider strategy will not be possible if those vendors are forced to offer a fully functional EHR. The cost of developing a fully functional EHR is too high to sell the product at low prices.

Will a CCHIT Certified EHR improve my practice's income?
CCHIT claims to “open up the flow of HIT incentives from payers and purchasers.” Indeed, CCHIT specifies the functionality needed to measure and report on those quality indicators required for pay-for-performance incentives. In fact, CCHIT is the only federally recognized certification body for EHRs and is therefore important to any physician practice seeking to participate in upcoming payment incentive programs from the Centers for Medicare & Medicaid Services (CMS). Meanwhile, CCHIT Certified EHRs qualify for a special exemption from the Stark and anti-kickback laws, so that local hospitals or health systems can subsidize a physician's EHR purchase. Non-certified EHRs can also meet the exemption, but CCHIT is a reliable means of ensuring the interoperability required for an exemption. Finally, some malpractice liability insurers offer discounts to providers that use CCHIT Certified EHRs. Keep in mind, implementing a CCHIT Certified EHR is not the only path to achieving these benefits and it is not a guarantee that a physician will be eligible for each of these incentives.

Do I need a CCHIT EHR to participate in my local HIE?
HIEs and Regional Health Information Organizations (RHIOs) are playing an increasing role in mandating how payers and providers in a region share patient information electronically. In fact, there are recent examples of these types of organizations mandating that physicians adopt a specific EHR before “hooking up” with the exchange. For example, Partners HealthCare System in Massachusetts required all of it's primary physicians to have adopted electronic health records by Jan. 1, 2008 and all specialists to adopt them by the end of 2009. To retain their network status, physicians in the network were required to adopt either Partners' own EHR or another EHR from GE Healthcare – both of those EHRs are certified. According to their latest report card, 98% of their primary care physicians and 83% of specialists have adopted full use of the EHR. Of course, that does not mean that all RHIOs will impose as strict a mandate, but the conservative buyer should certainly get a sense for their local exchange's EHR requirements before investing in a new system.

Conclusions and recommendations
CCHIT promotes that through their certification process, the organization “sets the bar for EHR products.” We agree. However, we question if that bar has been set too high relative to most ambulatory care organizations' current requirements and IT capabilities. Even if a majority of EHR vendors achieve certification, will physicians follow suite by adopting the functionality specified in the CCHIT criteria? As we review the list of CCHIT Certified EHRs, we recognize many great software products. We see great benefit to the features specified by CCHIT. However, we can't help but wonder how long it will take for the traditionally “late adopter” physician market to accept and implement the requirements specified by CCHIT's technologically savvy Commission.

So, in the interest of serving our provider audience, here are five key takeaways for use in determining CCHIT's role in your EHR selection:

• Review the CCHIT criteria yourself and determine the relevance of each to your ideal workflow. The criteria are well defined, so even if you do not need every capability, you could select a subset for use in evaluating EHRs for your practice.
• Understand the binary nature of CCHIT certification. If an EHR does not fully address each of the CCHIT requirements, it will not be certified. Therefore recognize that there are many good EHRs that may not achieve certification, but may still meet your requirements.
• Consider the requirements of your specialty. If you need EHR capabilities specific to your segment of medicine, realize that CCHIT does not yet cover specialties. You have to evaluate specialty requirements on your own.
• Do your homework on other critical evaluation criteria that fall outside CCHIT, including: ease-of-use, customer satisfaction and vendor viability. CCHIT is very clear that these due diligence items are the buyer's responsibility.
• Understand the biases of both CCHIT proponents and detractors. It is natural for these industry players to have strong opinions, just be sure to put them in context, do your own research, and understand that the ultimate decision is yours.