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Readers Write 8/27/08

August 27, 2008 Readers Write 11 Comments

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CCHIT, The 800-Pound Gorilla
By Jim Tate, EMR Advocate


Yes, it’s true. There is a monster in the jungle and he is devouring all that is creative and laying waste to the brilliant small companies trying to lead the way in HIT development. Only the giant dinosaurs will be left the divide up the swamp once the blood bath is over. We are doomed, the sky is falling, and the Mayan prophecies of the end of the world are coming true.

That seems to be the belief of those who rant and rave against the presence of the CCHIT.

I beg to differ. I remember all too well when there were NO STANDARDS. I remember physicians being completely at the mercy of salesmen with slick demos (now they are at least somewhat less subject to the snake oil speech). I remember the industry making minimal progress on interoperability until it became a standard. I remember when there was no forward pathway that gave any indication of where EHR development was headed.

Say what you will about the CCHIT. I have found it to be an extremely transparent organization that is helping level the playing field and make it safer for clinicians to take the plunge into electronic records. In my experience, the staff at CCHIT has been incredibly responsive and helpful providing answers and directing me to clarifying resources. They set the standard on credibility. Certainly more open, helpful, and responsive than any major EHR vendor I have every contacted for support.

So there it is. You can throw stones if you wish, but you ignore them at your own risk. The CCHIT is here and is becoming ingrained in the road that lies before us. As Dylan said, “You don’t need a weatherman to know which way the wind blows."

ICD-10 Risk Assessment
By Art Vandelay


Discussion around this topic will benefit us all.

With the changes to the ICD-10 coding scheme, I have classified our systems into four categories – highest risk, moderate risk, low risk and no-risk.

I determined the categories by considering a few areas of risk: (1) the perceived impact to their applications’ architectures; (2) perceived capability of the vendor to handle these types of changes based on past experience with HIPAA and Y2K; (3) the vendor’s ability to share a plan for ICD-10 (few have been thinking ahead); (4) the vendor’s use of ICD-9 in application and interface logic, such as order checking rules and code-to-procedure checking rules); and (5) the use of discrete ICD-9 or groups of ICD-9s to drive key reports.

After considering the areas of risk, our main ancillaries (pharmacy, surgery, pathology, radiology) and revenue cycle add-on products are in the highest-risk category. Also in the category is our EHR. This was only due to the decision rules around the EHR and the way the department-focused portions of the EHR are used. It could be much worse here if we were using more reporting or decision rules. The revenue cycle add-on products are the most troubling. These include claims scrubbing, coding rules, and charge edits.

In the moderate risk category are our revenue cycle, scheduling, medical records, and decision support products. The revenue cycle vendor has a decent plan in place.

The low-risk category includes many of the biomedical and patient education applications. These applications do not have much logic associated with a diagnosis. They also do not send interpreted data outside of the system. Some raw data without diagnoses is sent.

The no-risk category includes our enterprise resource planning (ERP) systems and document imaging system.

ICD-10 also enables the HIPAA-compliant claim attachments. We have not performed this risk analysis, but believe our EHR product will help. My fingers are crossed.

Because of this change, the independent physicians may start to approach the hospitals for some EHR-Practice Management system donations under the Stark and Anti-kickback law changes. This will place the hospitals in the unenviable position of thinking about themselves and their projects versus keeping the physicians happy. It could also impact the forms, order sets, and other data to be built in these applications because there are more possibilities to consider.

We have added ICD-10 contract language to our list of the usual items we negotiate with both our systems and medical devices. This mirrors our HIPAA and Y2K language.

Soarian Financials
By Clinton Judd

Last week, Otis Day clarified his positive comments regarding Soarian development to say he meant Soarian Clinicals, not Soarian Financials (SF). He went on to say, "I do agree that Siemens is looking to improve short-term and milk INVISION. And why should Siemens care, or the customer, for that matter? If the customer is happy (and paying their invoices), where’s the problem? Does Mr. Judd suggest this is a negative situation?"

Soarian Cynic answered this in Monday’s HIStalk by detailing how his hospital has waited six years for SF and they were recently told to wait at least two more (and asked to extend INVISION for at least five more, just in case). This is two years before SF is ready for them to start implementing. Hospitals have been hurt by the delay. They have been sold on the functionality to come in SF and, as a result, accepted that INVISION would stop being enhanced (not sunsetted, but few significant enhancements in years). 

If hospitals had known in 2005 that they wouldn’t have an integrated contracted management system or an integrated EMPI until 2012, they may well have solved their revenue cycle challenges with Eclipsys’ Sunrise Financials (formerly SDK) or they might have invested in bolt-ons to INVISION to get them the process improvements they sought. Waiting for Soarian Financials has frozen some hospitals with respect to patient access and revenue cycle improvements at a time when they desperately need to improve and be efficient. CIOs (particularly ex-CIOs) have been hurt by the Soarian delays, too.

Despite still collecting high-margin INVISION fees, Siemens has been hurt, too. For example, Monday’s HIStalk mentioned Oregon Health Sciences’ (OHSU) implementation of Epic to replace A2K and LCR (A2K is OHSU’s name for INVISION). Siemens lost a very big customer there to Epic. Soarian simply wasn’t ready to compete with Epic and a number of other very large accounts nationwide have or will make the same decision to stop waiting and go with Epic. Similarly, I have heard (second-hand) that MedSeries4 has lost a number of customers to Meditech in recent years. Perhaps Soarian would have helped there too.

The difficulty with Soarian Financials isn’t because there aren’t a whole lot of good people trying hard. Siemens has invested a ton in this effort (I think SMS started the effort in 1998). The challenge is that Siemens is replacing INVISION.

INVISION certainly has its weaknesses and shortcomings, but customers have done a lot with it. It is surprisingly flexible and open to integration, if you have the skilled resources. This flexibility will make (has made) it very hard to replace. It’s the hospital’s billing system, so any replacement has to do everything INVISION does plus more. SF not only has to be a super, everything-to-everyone solution, but it effectively has to be backward-compatible too. 

Oh, and it needs to keep up with the market too. Ten years ago, it didn’t need a patient portal for billing and self-scheduling, but it needs one now. Five years ago, it didn’t need registrar score cards; it needs them now. Three years ago, it didn’t need a patient payment estimator, but it needs one now. These are all bolt-ons Siemens’ customers keeping connecting to INVISION and now want in SF or require SF to integrate to. 

The goal line for Soarian Financials keeps moving back. I don’t envy SMS/Siemens for having to create a replacement to INVISION. 

Siemens has done much better with Soarian Clinicals, as Otis Day commented on. Soarian Scheduling is more like SF; at least one regional medical center de-installed Soarian Scheduling after just months of use for scheduling radiology.

When Soarian Financials is finally ready (however ‘ready’ is defined), the next challenge for Siemens and its customers will be the conversion process. Implementing SF is a massive, long project — a 24-month effort? It is supposed to replace the entire revenue cycle, soup to nuts. Everything. Siemens probably still has 400-500 hospitals using INVISION. How many can they convert/implement a year? If they can do 50 a year (one a week), they’ll need 8-10 years. That’s IF they could do 50 a year. If anyone has heard Siemens’ answer to this conversion/implementation effort, I’d be interested in what they think they can do.

So, Soarian Cynic, if I were your hospital’s CFO, I’d either sign up for five more years of INVISION (maybe get a better price for seven years) and beef up your bolt-ons (there are great solutions available to enhance your access/revenue cycle processes).

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Currently there are "11 comments" on this Article:

  1. While I mostly agree with Mr. Tate on the positive effects of CCHIT, he is being (slightly) intellectually dishonest. The costs associated with compliance or adherence to ANY set of standards will disproportionately affect a small company compared to a larger one (which should have more money to throw around). The reason why big businesses speak out so positively about standards or regulation is because compliance will hurt their smaller competitors. Dispute it all you like. Sometimes one’s feelings and objectively verifiable facts are different.

    With that said, CCHIT has no involvement with (or money from) any government entity that I know of. CCHIT, whatever imaginable problems might exist, is preferable because: it is private, industry professionals have the ability (in theory) to help determine the standards, and if ultimately CCHIT does not represent the industry well, it will go away (and likely be replaced by another industry certification organization). Much better that the industry regulates and develops standards itself.

    Sorry for the lengthy reply.

  2. Wompa1:

    From CCHIT’s FAQ:

    “In October 2005, CCHIT was awarded a contract by the U.S. Department of Health and Human Services (HHS) to develop, create prototypes for, and evaluate the certification criteria and inspection process for electronic health records (EHRs). The HHS funding is transitional, designed to support certification development, testing, and assessment, after which CCHIT will transition to a self-sustaining model.”

    What is not stated is that CCHIT is being (mis)used as **the** measure of entry onto the short list of many private- and public-funded EHR endeavors. Here’s one example:

    The state of VT offers $$ if a practice chooses one of the 6 pre-screened EHRs, the primary measurement of which is CCHIT certification. There are dozens of other examples, as each of the vendors on this list has had some pretty awesome business in the last 12m, thanks to CCHIT.

  3. Wompa1 said ” The costs associated with compliance or adherence to ANY set of standards will disproportionately affect a small company compared to a larger one (which should have more money to throw around).”

    That is only true of big vs small companies from the same starting position. If said big company already has legacy non-CCHIT to support then that is a disadvantage to smaller company IMO.

    It’s like the train tracks. It’s really arbitrary how far apart they are. What’s important is that they all are the same. Imagine re-engineering a huge rail company where the wheels don’t fit the tracks anymore. Keep in mind that CCHIT keeps making the standard more strict as time goes on, so soon it may matter how thick each rail is and then what kind of metal, etc.

    Some big companies are waiting to be displaced IMO. Many by small companies who have nothing to lose by building with CCHIT standards in mind from the start. Not all EHRs are CCHIT certified yet…

  4. Dear Art:

    Like anything else in this world, there will always be believers of entities which are just plain wrong. CCHIT was established by software vendors FOR software vendors and it is anything but transparent, especially after I began highlighting the fact that this not-for-profit’s incorporation papers stated that at the end of the year all profits would be given to those “big boy” EMR vendors that incorporated this entity. Later, in their 8/2006 minutes they were predicting a million dollar profit for the first 6 months of 2006. After 8/2006 all posting of minutes were stopped and when resumed on 11/2006 they were concise and scrubbed, without any detail, and continue as such to the day. On 12/2006 they reincorporated CCHIT.
    URL where you can download these now hidden public documents: http://www.msofficeemrproject.com/Page3.htm

    CCHIT is simply not necessary. I remember those times when in CMS had the “National Standard Format” for billing. All a vendor had to do to make it into the “gold list” of vendors was to call CMS and run a test to see if their software could communicate with the CMS servers. That was it- there was no cost, and the process was easy.

    Now, to get the 1st year CCHIT certification it used to cost a total of $28000.00 with a cost of $4000 to keep the certification active on years 2 and 3; in many situations, s.a. to work in a Stark-relaxation-kickback environment the vendor has to recertify yearly at $28000.00 a year. For 2008, the application cost for CCHIT is now $29,000 application plus $6,000 for maintenance for a grand total of $35,000. (http://www.emrupdate.com/forums/p/14875/84917.aspx#84917) This cost is simply outrageous and an unnecessary burden for both vendor and for the physician purchasers.

    >>> I remember all too well when there were NO STANDARDS.

    You haven’t done your homework- there have been numerous “standards” that have been forwarded over the years, all of which have failed to be universally accepted. This list of recognized “standards” and “standards organizations” is not a complete list. Some of these “standards” date back more than twenty years. The number of these organizations and the failure of every single one of them to become the recognized standard attest to the reality that no electronic standard is possible in a dynamic and innovative field like medicine. Some of these organizations have sued other organizations, some of these standards have multiple variations of the same standard, there are many competing standards in the same discipline:
    • ASTM International Continuity of Care Record – a patient health summary standard based upon XM.
    • ANSI X12 (EDI) – A set of transaction protocols used for transmitting virtually any aspect of patient data. Has become popular in the United States for transmitting billing information, because several of the transactions became required by the Health Insurance Portability and Accountability Act (HIPAA) for transmitting data to Medicare.
    • CEN – CONTSYS (EN 13940), a system of concepts to support continuity of care.
    • CEN – EHRcom (EN 13606), the European standard for EHR systems.
    • CEN – HISA (EN 12967), a services standard for inter-system communication
    • DICOM – for representing and communicating radiology images and reporting
    • HL7 – HL7 messages are used for interchange between electronic systems and devices. There are two different versions in use.
    • ISO – ISO TC 215 has defined the EHR, and also produced a technical specification ISO 18308 describing the requirements for EHR Architectures.
    • openEHR – public specifications based on a complete separation of software and clinical models.
    • Current Procedural Terminology (CPT): A classification system for coding ambulatory care.
    • ELINCS – EHR-Lab Interoperability and Connectivity Standards: An standard for reporting laboratory test
    • IEEE 1073 – Institute of Electrical and Electronics Engineers: The 1073 standard is used for integrating a medical device to a clinical information system
    • ICD-9 – International Classification of Diseases: is used for diagnosis and procedure coding; many are pushing for adoption of ICD-10 (a good example of the need for verbosity to determine a common medical knowledge set)
    • LOINC – Logical Observation Identifiers, Names and Codes: A code set covering laboratory tests
    • Medcin – A terminology for clinical care.
    • SNOMED International – A terminology for clinical care.
    • NCPDP – National Council for Prescription Drug Programs: A suite of standards governing prescription transactions.
    • NDC – Federal drug agency standard drug identification system
    • Multum – standard drug identification system.

    (list from: http://www.emrupdate.com/forums/p/8530/63273.aspx#63273)

    Sure, CCHIT is now “THE” recognized standard, but only by political decree by HHS Leavitt. I hope that one day we can add CCHIT to this list…

    >>> I remember physicians being completely at the mercy of salesmen with slick demos…

    And you feel that CCHIT will change this? Although CCHIT promises “assurance”, they do not certify usability, they do not certify customer support, they do not promise increased income, and they do not certify that a vendor is financially sound. They have yet to standardize interoperability, although they continue to promise to do so. Finally, they will not change the character and integrity of a vendor and its salespeople.

    >>> I have found it to be an extremely transparent organization that is helping level the playing field and make it safer for clinicians to take the plunge into electronic records.

    Above, I have noted how not-so-transparent CCHIT is nowadays. How do you find it safer for clinicians? CCHIT certification essentially means that the EMR will cost on average twice as much. At http://www.emrupdate.com we have a listing of EMR systems and their associated costs for a 2-member group practice. All the CCHIT certified EMRs cost over $31000.00 while non-CCHIT certified EMRs average about $17000.00 (check out “What is Wrong With HIT in the USA?”, slide 44, here- http://www.msofficeemrproject.com/Page3.htm). This means that CCHIT will force clinicians to put more money at risk, with the odds against them of getting a decent return on their investments (“ROI”).

    >>> The CCHIT is here and is becoming ingrained in the road that lies before us.

    Nobody will really know what is destined for the future. What we do know is that: physicians are NOT endorsing CCHIT. If you look at the 10.31.2007 Biennial CDC report, although uptake of “any EMR” has increased to a 29% level, the growth of CCHIT-certified EHRs has grown to a 12.4% level, up from 9.3% in their last study, a level which is NOT statistically significant. Unless physicians. Unless physicians come on board with this, CCHIT is going to be a dead end. Go to any physician-only site, s.a. http://www.sermo.com or http://www.docsboard.com, and you will see the anger and negativity towards CCHIT first-hand.

    >>> Only the giant dinosaurs will be left the divide up the swamp once the blood bath is over. We are doomed, the sky is falling, and the Mayan prophecies of the end of the world are coming true.

    Ok- don’t just look at the fact that CCHIT-EHRs are twice as expensive. Look at other data, published in a document downloaded from CCHIT called “EHR Certification has Strong Acceptance in the Marketplace”: “…43 percent reported annual revenues greater than $10 million…” (URL: http://www.cchit.org/about/news/releases/2008/EHR-Certification-Strong-Acceptance-Marketplace.asp)

    Although I disagree with you, thank you for bringing up CCHIT so that we can clear the air.

    Al Borges MD

  5. …except, like train barons before them., the larger companies have the resources to contribute and DRIVE the CCHIT agenda in a way that the smaller companies do not. Look through the lists of workgroup committees. See any OSS people there? How many small companies are present? It’s almost nearly all big groups, from the EHRs themselves to the insurance companies. Someone has to pay for those hotel rooms and plane fares and time on the phone – the smaller companies don’t have those resources. It would be nice if CCHIT could reach a point of funding that it could subsidize some of the missing voices.

  6. Kraken said: “like train barons before them., the larger companies have the resources to contribute and DRIVE the CCHIT agenda in a way that the smaller companies do not.” I could not have said it better.

  7. Siemens HIS days are numbered. They designed (on purpose if you can possibly believe it) a new HIS as 3 distinct and incompatible products – Financials, Scheduling, and Clinicals. The unfortunate Alpha partner hospitals have to build 3 completely separate reference databases and maintain them in sync.

    The databases are so incompatible the integration between the 3 is using HL7 interfaces !

    Cerner must be laughing all the way to the Leeds (sorry UK readers may get that).

  8. For obvious reasons, I wish to remain anonymous.

    I used to be a reader of emrupdate and really appreciate the diligence of Dr. Borges on the issue of CCHIT. I, too, was among the critics of the certification and, in many ways, still am.

    Although I can’t speak to the behind-the-door dealings of the organization, I can speak to the quality of the folks serving on the workgroups – as I am serving on one now. Yes, as RtK noted, the groups are comprised primarily of folks from large-organizations. And, at least in some of the other workgroups, I sense that some members are there are “placeholders” for their employers.

    However, I admit to be pleasantly surprised by how knowledgeable, dedicated, and earnest most of the folks I’ve met (particularly in my workgroup) really are. I like to think I know what I’m talking about in my niche within a niche, but what an eye opener it was to meet so many folks with deep(er) backgrounds.

    Sure, I question many parts of the process as we go, but at the micro level, I see nothing but dedication towards “doing it right.” Don’t get me wrong: I am still very much concerned with the CCHIT certification issues (Jim Tate: do you really believe CCHIT makes the sales people LESS slippery? It’s made them WORSE!), but I do think there may be some positive results.

    Dr. Borges, one thing I’d like to add to your list of standards is the fact that even when two entities agree on a given “standard” there is, within each of them, so much room for interpretation that it’s almost worthless. Anyone here who talks about being HL7 compliant – and thinks it really solves a problem – has never personally written an interface. Boy, even the good ol’ HCFA-1500 form – everyone remember when that switched years back? It’s as “standard” as you can get…with 1001 different ways to complete the data within it.

    I LIKE the idea of standards. I just see so few done properly.

  9. CCHIT is extortion.

    a) The big boy vendors club together in a common cause to foist their hospital software into physician offices because the requirements must be the same right?

    b) They come up with a common list of features that they all had to implement in their hospitals.

    c) They then write them up along with some test cases and then extort $30,000 (actually more) from small businesses to polute their own software with these near useless features.

    d) With lobbying they open the door for hospitals to further add to the problem and proliferate the need for CCHIT certification.

    e) The cash rolls in, they announce multi-million dollar profits which they share among themselves in accordance to their incorporation policy documents.

    f) Given the success of this ploy they increase prices and prepare to drive small businesses out of business.

    Another government intervention folly – if the features are needed so badly the vendors would already be supplying to meet demand.

    Physicians are too smart to put up with this for long.

  10. Mr. Rush:

    You actually read and posted at emrupdate, the place where they came up with the anit-CCHIT standard idea, “SHOVEL”, and you still volunteered for a CCHIT workgroup? Did you not learn anything?

    Kidding aside, just don’t let them use/abuse your efforts. At the least, make them **pay** you; they do make a lot of money and can afford it.


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