Is HITECH Working? #3: ONC got it right on the 3 major policy interpretations: Meaningful Use, Certification, Standards

We concluded our last post in this series with a blunt prediction that “key physicians will sit on the sidelines” and that clinician non-adoption of EHR technology is a potential “deal-breaker for the success of HITECH”.

While this might sound like a criticism of the way HITECH has been implemented, it’s not intended that way — it’s a commentary on 1) the complexity and scope of change that will be required to make HITECH successful, and 2) the level of protective entrenchment existing American health care today.

Rather, we believe that the Office of the National Coordinator (ONC) for Health IT – Dr. David Blumenthal and his staff — have done a superb job in interpreting and defining key aspects of HITECH legislation. We’re big fans.

For those of you who have been following our writings over the past 18 months, think of this post as a summary and status report on the extensive incumbent (cat) vs. innovator (dog) dialogue:

  1. A Recap  — The Stagnant Electronic Medical Record (EMR) Market Before 2009
  2. ONC Gets It Right In Three Major Interpretations and Definitions of HITECH

a) Meaningful Use (MU) Emphasizes “Meaningful”, Not “Use”

b) Vendors Get a Level Playing Field With Certification

c) Lightweight, Open Standards Promote EHR Interoperability and Modularity

Is HITECH Working? #2: Key physicians will sit on the sidelines (at least for now).








(click on any of the above graphics to be linked to the orginal source)

by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA

In the previous post in this series on “Is HITECH Working?”, we straightforwardly noted that hospitals are playing in the HITECH game. The issue of whether physicians will play is MUCH thornier.

As the headlines above succinctly convey — we conclude that for now there is too much fear, uncertainty, and doubt (FUD) to expect significantly increased EHR technology adoption by most physicians from the HITECH incentives and penalties.

Here are topics we’ll cover today:

  • Fear, Uncertainty, Doubt
  • Little Risk by Waiting a Year or Two
  • A More Granular View — Segmenting Physicians
  • Is There Another Side to the Story?
  • How Important is Physician Adoption to the Success of HITECH?

Is HITECH Working? #1: Hospitals are grumbling but are playing in the game; success is not guaranteed.


by Vince Kuraitis JD, MBA and David C. Kibbe MD, MBA 

The rationale for hospitals having to play in the HITECH game is straightforward: the financial carrots through 2015 are helpful, and the financial sticks after 2015 will be very painful.

We’ll discuss:

  • Financial Impacts on Hospitals
  • Survey Data Showing Hospitals Will Play
  • Why Success is Not Guaranteed

Financial Impacts on Hospitals

Even prior to HITECH, most hospital executives already had passed the threshold decision and concluded that they need to implement EHR technology. Thus, the issue for most hospitals isn’t “whether” to implement EHR technology, but “when”, “at what cost”, and “how”.

A Compendium of Perspectives on the HITECH Certification NPRM

Just the Facts 

Certification Programs NPRM (Notice of Proposed Rulemaking)

Health IT, U. S. Department of Health and Human Services; March 2, 2010

Certification NPRM




Bookmarked version of Certification NPRM (much easier to navigate)

U. S. Department of Health and Human Services; March 2, 2010

Via OCCAM Practice Management blog, March 3, 2010


Commentary and Analysis


Proposed EHR Certification Rule Changes Game

HDM Breaking News; March 2, 2010

“The rule mentions the Certification Commission for Health Information Technology, but does not grant it any grandfather status…. So, while CCHIT appears to be able to continue its operations under the proposed temporary certification program, its future isn’t clear in the proposed permanent program.”


Certification NPRM: A Statement from Alisa Ray, Executive Director, Certification Commission for Health Information Technology (CCHIT)

EHR Decisions; March 3, 2010

“…we feel confident about our prospects of becoming accredited…. We feel confident about the future, and we look forward to the opportunity to continue playing a role in accelerating the adoption of health IT.


 Why Rush Vendor Certification of EHR Technologies?

The Health Care Blog; March 08, 2010

“David Blumenthal and his staff have unveiled two separate plans to test and certify EHR technology products and services. We don’t think this is a good idea…this recently-announced two-stage EHR technology certification plan bears all the marks of a hastily drawn up blueprint that, if rushed into production, could easily collapse of its own bureaucratic weight.”


HIT Leaders React to Proposed EHR Testing and Compliance Rule

HealthLeaders Media; March 4, 2010

  • “They got it exactly right.” Simeon Schwartz, MD, president and CEO of WestMed Medical Group.
  • “It’s going to be interesting to see how much the vendors got out ahead of this and how much they’ve hedged their bets” Eric Saff, CIO of John Muir Health
  • “…no matter where you are in the chain of this market, you can in fact certify those modules as opposed to waiting until you meet complete meaningful use to be certified. So I think that’s great. I think that’s really considerate of the ONC.” Luigi Leblanc of Solink

John Halamka’s Stunning 180: “Dogs and Cats Should Live in Harmony”

The King of the Cats has just acknowledged that indeed cats and dogs should co-exist peacefully.

Dr. John Halamka — Vice Chair of the HIT Standards Committee of the ONC and one of the most vocal and influential figures in health IT — writes a blog post this morning entitled “The Genius of AND”. Halamka reasonably summarizes the essence of the debate about standards and interoperability as being between “the healthcare informatics crowd” (cats) and the “Internet crowd” (dogs):

He notes that the debate shouldn’t be about one or the other POV prevailing (“either/or”), but about integrating both points of view (“and”):

..we need to embrace both approaches – the right tool for the right job depending on what you want to achieve.

For provider to provider communication which requires the exchange of documents with non-repudiation as the medico-legal record for direct clinical care, the CDA/CCD has great metadata and the ability to support structured data as well as free text discharge summaries/operative notes/history&physicals.

For a summary record that represents a snapshot in time of problems, medications, and labs for transmission between EHRs and PHRs, the CCR and other formats such as Google’s CCRg or PDF can do the job.

I’m absolutely stunned…and speechless.

CCHIT’s Latest Gambit

by Glen Laffel MD, PhD

Many of us have enjoyed a few good minutes of fun having our fortunes told by soothsayers who claim they can predict our future based on patterns of tea leaves in a cup or the playing cards we’ve pulled from a deck.

We pay a few dollars for the entertainment and if the fortune teller is skilled, we are temporarily impressed by his “insight.” But once we leave the carnival, we come back to our senses. Fortune-tellers can’t predict the future.

With its latest announcement, the Certification Commission for Healthcare Information Technology (CCHIT) appears to have entered the fortune telling business.

And if information provided on blogs published by its founders is to be believed, some EHR vendors plan to have their fortunes told by the former EHR certification monopolist.


In June, ONC’s HIT Policy Committee released a Meaningful Use Matrix and proposed that it should serve as the basis for EHR certification as mandated by ARRA, the economic stimulus program signed into law last winter.

The Matrix consisted of five “Health Outcomes Policy Priorities” and associated Care Goals, Objectives and Measures. The Committee anticipated that the latter would be transformed into EHR certification criteria.

HIT Policy Committee Recommends “Minimum” Certification of EHRs

At last Friday’s meeting, the HIT Policy Committee adopted the recommendations of the Certification and Adoption Workgroup.

Between the initial recommendations in July and the adopted recommendations in August, one critical word was added to the definition of “certification”.  That one word is “minimum” — and this one word expresses the correct approach and philosophy for the government’s role in the certification process for EHRs.

In this post I’ll address why a “minimum” approach toward certification makes sense: 

  • Why “Minimum” Certification is Right: More Like UL
  • Why Current CCHIT Certification Based on Functionality Risks Irrelevance or Lock-in to Outdated Technology

UL - the standard in safety

Why “Minimum” Certification is Right: More Like Underwriters Laboratories

Time for EHRs to Become Plug-and-Play

by David C. Kibbe MD, MBA

The remarkable report, “Initial Lessons From the First National Demonstration Project on Practice Transformation to a Patient-Centered Medical Home,” published in the May/June issue of Annals of Family Medicine, the Nutting Report, makes this point about the state of primary care IT offerings:

Technology needed in a PCMH is not “plug and play.” The hodge-podge of information technology marketed to primary care practices resembles more a pile of jigsaw pieces than components of an integrated and interoperable system.

Surprise!  Well, actually, no surprise.  We all recognize that health IT implementation in family practices, even under the best conditions and with the best of planning, is difficult and can be an ongoing challenge.   

What is surprising to us, however, is that Dr. Nutting and co-authors make this comment in their recommendations section:

…[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connections, evidence at the point of care, disease registries, and interactive patient Web portals without an EMR.

Markle v. HIMSS: Differing Views of “Meaningful Use” and “Certification”








The forthcoming definition of the “meaningful use” of health information technology will set the direction of the Obama administration’s strategy for health IT adoption, said David Blumenthal, the new national coordinator for health IT. Government HealthIT, April 28, 2009

…but not everyone sees eye-to-eye on the definitions of “meaningful use” and “certification”.  [See the first post in this series for a refresher on the dog (disruptive innovator) and cat (incumbent EHR vendor) points of view.]

Markle Foundation –  Best Articulation of the Dog (Disruptive Innovator) POV 

Achieving the Health IT Objectives of the American Recovery and Reinvestment Act
A Framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR
Markle Foundation; April 30, 2009

HIMSS and EHRA — Best Articulation of the Cat (Incumbent EHR Vendor) POV 

HIMSS Publishes Its Definitions of ‘Meaningful Use’
HIMSS News; April 27, 2009

HIMSS Electronic Health Record Association Executives Testify at NCVHS Hearings on ‘Meaningful Use’ Criteria
RedOrbit; April 28, 2009

Many Others Weigh In….

Is the Health Data Liquidity Glass Half Empty or Half Full?

Glass What a difference in attitude! Compare two press announcements from April 5:

1) CCHIT:  Interoperability Isn’t Doable With Today’s Technology .

Certification Commission for Health Information Technology (CCHIT), Interoperability: Supplying the Building Blocks for a Patient-centered EHR , April 5, 2009

This report…(is)  also an attempt to inject a dose of reality into the discussion of interoperability – from practical expectations for the near term and future years to the challenges of developing software architecture and implementation guides that can execute new interoperability criteria uniformly and successfully.

2) New York Presbyterian/Microsoft: We’re Creating Patient Data Liquidity Today!

New York-Presbyterian Hospital Pioneers New Personal Health Record, Press Release; April 6, 2009

Patients can reference their actual, up-to-date health records, which are organized and stored through Microsoft’s Amalga and HealthVault technologies and stored by the patient in a personal account following visits to their hospital, doctors and health care providers.