Maintaining EHR certification requires planning and a budget, CTO says

Health Level Seven International (HL7) is one of many organizations that offered comments on the proposed rule from the Office of the National Coordinator for Health Information Technology, or ONC, for establishing a temporary electronic health record (EHR) certification program. Now that the final rule is out, organizations can begin testing and certifying health IT.

Purchasing and implementing a certified EHR system is only the first step, however. In this video, John Quinn, HL7's chief technology officer, warns that maintaining EHR certification could be a disruptive process. Health IT professionals will have to plan accordingly for software updates, which may require hardware improvements. He also offers a bit of advice for smaller providers who are new to the EHR technology market.

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Read the full transcript from this video below:  

Maintaining EHR certification requires planning and a budget, CTO says

Don Fluckinger: Hello. I am Don Fluckinger, with
As you know, the meaningful use rules are out, and the mad rush for
compliance has already begun. HL7 Standards played a big role in
shaping those meaningful use rules, in fact, five of them, guidelines
or standards, are mentioned by name in the 800-page meaningful use
document. We sat down with HL7 CTO John Quinn at the recent SOA
in Healthcare Show, in Washington, D.C. to ask him what
physicians and CIOs need to know about HL7 standards as they
relate to Meaningful Use.

ONC came out with its final rule for temporary certification.

John Quinn: First set of final rules. I look at it as, due to be updated
at some point. Maybe next year.

Don Fluckinger: Fair enough. You had, you, meaning HL7, had offered
comments on earlier proposals. What is your perception of the rule came
out? Did you get what you want?

John Quinn: We made suggestions, but I do not think the
suggestions were earth-shattering in any way. A lot of it had to do
with the use of, what we are talking about before about NIST, what
NIST is dealing with and probably the most immediate piece of HL7
that actually is in the mix, is the EHR functional model, which
was what CCHIT used during the Bush administration. This model
functional model of electronic health records; what constitutes
an electronic health records system? By features, it is
something the government has been using and NIST is using. There
are a couple of other profiles associated with this that are
coming into play now, that NIST is looking at, not for this
phase, the next form is the interoperability paradigms, or
interoperability model. In other words, I can build functionality
the next thing is interoperability, and that is inferred, when
you take a look at the rest of the rules, they are saying,
'During this round, the physician needs to collect data. Next
round, the expectation is that . . .' at least preliminary when
we were looking at spreadsheets coming out of ONC, back before
the interim final was published for comment was, 'Moving that
data is something that is going to have to start happening in
2013, October 2012. Moving that data in full-coded form would be
something that would have to happen by 2015,' so that
interoperability model now becomes far more important. The
third piece if it, is the lifecycle, which is more of software
engineering type thing, but it is really important, because one
of the things that I found in talking to some of my clients is
that the current approach that… let us say you implemented
an EHR system, you did a really good job, and you have really
good adoption maturity and I know several organization have
done it. Installing updates that come out every year, forget other
ones, not the emergency fixes that fix dire bugs, but things that are -
we got a new update. Most vendors publish a new update at least once
a year. Good ones publish them just about once a year.

Updating electronic is very disruptive, both to your department,
in terms of, 'I have to get the new software, I have to load it
to a different environment, we have to configure it to our
configuration, we have to test out the interfaces, we have to
test out our code sets, so on and so forth; I understand. The
other thing that happens that is maybe not quite so obvious, is
that most of these vendors are increasing their functionality
and increasing the technology; improving the technology.
Healthcare tends to lag other IT technologies, so we have
things like, better think line implementations, architectures
that are faster, that are more easily supported, that require,
in some areas, less hardware, and in some areas more hardware.
As these new updates come out, there is new hardware budget
requirements associated with the hosting of them - so two issues.
One is the disruption to your user base, which is probably the
most important. You got adoption, but that does not mean you are
guaranteed adoption forever. You start fooling around with the
stuff, slow somebody down, and they are going to stop using the
system. The second is your hardware budget for the year. And if
you have not been in the habit of doing that, it might come as a
surprise, but it should not, that as these things change, the
vendors are willing to absolutely support having certify certified
system, but they are not going to support certification across
multiple older versions of their product, so you are going to
have to stay current. That is a new effort and a new expenditure
by both the IT department and the user groups within an IDM that
are going to be affected. Even though established systems that
are out there, that have been making good use of the EHR systems
over the last several years, are going to find that the rules
are disruptive, and will have to be planned. You cannot just
say, 'We got an update, slam it in.' That always has a very bad
outcome if somebody does that. You have to be able to budget and
you have to use people -both technology and medical - to effect
a smooth transition.

Don Fluckinger: Obviously, talking to larger hospitals and larger EMR,
EHR installations, most of them already have an EMR.

John Quinn: Of course, they have an EMR. They may not have everything they
need, but, yes.

Don Fluckinger: Right. Setting them aside for a moment, what bit of advice or
encouragement would you have for the small physician practices,
clinics, and solo physicians who are just getting into the
technology - or some of them might be dragged, kicking and
screaming into it.

John Quinn: For starters, let us look at how this segments out. I have
talked to a number of physicians who are about my age; I am in my
early 60s. If you are a physician in your mid-50s forward, my
general reaction, when I talk to my friends that are physicians,
they say, 'Yes. I have heard about that. I am not going to do
it.' I say, 'What are you going to do in 2016?' They say,
'Retire.' They may do that because they are 60, 65, 70, but it
does not make any difference, they have viewed that as an
investment they are not willing to make, and I understand.
Disappointed, but personally understand. For the rest out there,
that basically say this is something my career really depends on
going smoothly, I first and foremost, look to my professional
organizations. I know there is some family practice, a rental,
whatever, whatever your practice specialty is, I looked
at that organization first. I work with a lot of them in HL7, we
work with a lot of the different specialty organizations, and it
is clear that it is very important that those organizations,
since they are effectively, the lifeline, in a professional
sense, for information, advice, partnering, swapping stories,
and figuring out what to do amongst them; nobody is going to
advise them better than they will. I say that because you are
talking specifically about groups of physicians that are so
small, that hiring a consultant is probably not rational. If you
are a group that has maybe got six, ten, or more physicians, you
might find a consultant to help you out, but if you are a solo
doc, or a two or three physician practice, you probably do not
have the financial budget to support that for any sustained
period of time. You have somebody who can give you some advice
and walk out the door, but not somebody who can come in and
actually help you put it in.

Then the next step is, I would be looking for applications that
are easy to get a hold of and easy to implement. In other
words, if somebody says, 'No problem, you put these six PCs
around your office, you put these two servers in, and you hook
this up to the internet,' that is already starting to look like
something that, as a physician, you have to be awfully
technically savvy to deal with. I would be looking for solutions
that are being offered in the market that offer - essentially, it
is about as difficult to set this up as it is to set up my DVR,
or my flat-panel TV. I might need to call an 800 number, I might
need to get some advice on plugging the cables in, and the advice                                                                        that I am hearing from that professional
organization, is the system has a rating of 83% or more. We are
happy with the kind of people, the physicians like you that we
have surveyed in our membership. That is the kind of stuff I
would be looking for. In other words, I would be looking for the
consumer reports for physicians. Consumer reports might well end
up with something like this, but I would be looking for the
consumer reports for physicians that actually are part of their
specialty professional organization.

Don Fluckinger: My last question is, and I guess I would understand if
you demurred on this, but it seems like there probably will be multiple
certifying agencies for EHRs. What is HL7's official position on
that? The more the merrier, or . . .

John Quinn: Yes. HL7's official position is I do not think we have an
official position. We support NIST, we have worked closely with NIST.
NIST has been working with HL7 since the day the law was passed,
so I see all kinds of folks from NIST that I either meet with
between meetings, or I talk with and meet with at HL7 meetings.
A number of people in the industry I have worked with over the
years in other aspects have joined NIST to help them, and are
now present at these meetings. And they are there primarily to
learn, not to write the standards, but to figure out what is the
best way that NIST could organize them, the use of HL7, going
forward eventually to interoperability, specifications and
profiles to the group of agencies that are going to become
certifiers. I have listened to and I have seen a couple of
presentations from ONC about what they have done
with NIST, certifying, and certifying certifiers, and so on and
so forth. Those all make sense to me.

The more the merrier? When you really get right down to it, an
awful lot of certification is going to have to happen. That is
fine. Automation of certification, in some way? Absolutely,
where it makes sense to do it. Do not create a process where a
vendor has to come in, set up a system, and spend a week with a
team of people to demonstrate that they have met certification,
because what is that going to do? That is going to jack the
price of the systems up, there is almost no other alternative
because of the expense. It is also going to create an
environment; it would create an environment where the small EMR
entrepreneur or lender could not survive. Clearly, that was part
of the intentions, both in . . . I read that, to a certain
extent in the law, it was hard to understand the law and
certification when you looked at it from the current
environment, which was CCHIT alone. When you sat through some
of the Policy and the Standards Advisory Committee meetings,
listening online, or being in person, it became pretty obvious
that Dr. Blumenthal's intention and John Blasco's, as well, was
at the time, was to come up with a way where we are going to
end up with multiple certifiers so that we can bring the price
down. We need to do certification, but in the UK they do
certification and it is largely automated, and I am familiar
with that. Again, we are not at the cutting edge of some of this
stuff; there are lots of folks that have gone and taken this
path and we can learn a lot from them, but it would certainly
help the industry as a whole. This is a very expensive endeavor -
time, effort, and money - and it is important that we not create
artificial barriers, so I think a lot of suppliers is fine.

I think from HL7's perspective, it is all about NIST. The
certifiers could certainly work with HL7, that is not a problem,
like CCHIT in the past, but the reality is, is that congress has
given that role to NIST. NIST obviously needs to cooperate with
ONC to make that happen, which apparently they have, certainly
from conversations I have heard from both sides, that seems to
be happening a lot, so that is good, too.

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