User Fees for Electronic Health Records?

President Obama has released his 2014 budget proposal, which includes $80.1 billion in spending for theDepartment of Health and Human Services (HHS), an increase of  $3.9 billion. The proposed budget for The Office of the National Coordinator for Health IT (ONC) would increase its $61 million budget to $78 million, a 28% increase. The plan also includes a $1 million fee for electronic health record vendors that would almost certainly be passed along to users of the systems.

“In addition to the expanding marketplace and corresponding increase in workload for ONC, much of the work to date has been funded using Recovery Act funds scheduled to expire at the end of FY 2013. Consequently, a new revenue source is necessary to ensure that ONC can continue to fully administer the Certification Program as well as invest resources to improve its efficiency,” the ONC explains in the budget proposal appendix.

In particular, the fee could be used to fund:

  • Development of implementation guides and other forms of technical assistance for incorporating standards and specifications into products
  • Development of health IT testing tools that are used by developers, testing laboratories and certification bodies
  • Development of consensus standards, specifications and policy documents related to health IT certification criteria
  • Administration of the ONC Health IT Certification Program and maintenance of the Certified Health IT Product List
  • Post-market surveillance, field testing and monitoring of certified products to ensure they are meeting applicable performance metrics in the clinical environment

If approved the collections will likely begin late in fiscal year 2014 and would be gradually phased in. According to the proposal “user fees would be collected from Health IT vendors,” and then “would be collected on ONC’s behalf by ONC-Authorized Certification Bodies (ONCACBs)” which already certify EHR systems as part of the meaningful use program. A fee structure would be established by the Secretary and published in the Federal Register, but a tiered system is being proposed where EHR modules would likely be assessed at a lower rate than a complete EHR system.

The HIMSS EHR Association opposes ONC’s proposal. “EHR developers are already devoting extensive resources to successful implementation of the EHR Meaningful Use Incentive Program and other healthcare delivery reform efforts, including the significant fees associated with EHR product certification,” the group said in a statement. I’m not automatically opposed to fees, however it is not the vendors that would ultimately bear the cost. My biggest issue with the EHR Incentive Program is that it should be more accurately called the EHR Vendor Incentive Program since these companies are making record profits and any payments to providers are simply a pass through to the vendors.

I would like to see steeper requirements for certification as future stages of meaningful use are developed. There are WAY too many products on the Certified Health IT Products List (CHPL) for small practices, community and critical access hospitals to make sense of and choose an appropriate vendor. When this program first launched a software developer friend reviewed the standards and certification criteria and claimed that she could design a product that would meet all of the certification requirements and yet be completely unusable in actual practice. I told her not to waste her time since it appeared that some companies had already done that…

Brian Ahier  blogs at Healthcare, Technology & Government 2.0 where this post first appeared.


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8 replies »

  1. Hi Brian,
    There’s a much smaller and more manageable product list at http://cchit.org .

    CCHIT’s own “CCHIT Certified® program goes beyond ONC’s Stage 1 and 2 MU testing criteria. CCHIT Certified® ambulatory and hospital EHR products are “inspected against integrated functionality, interoperability and security criteria independently developed by CCHIT’s broadly representative, expert work groups. Using CCHIT’s testing methods, these products have been found in full compliance with the criteria in effect on the date of inspection.”

    As of today, there are just 72 ambulatory and only 2 hospital EHRs that have achieved a CCHIT Certified® status. Although CCHIT also tests the EHRs it certifies for integrated functionality, interoperability and security for usability, their usability scores are not yet part of achieving the CCHIT Certified® status.

    CCHIT’s ONC-authorized MU certification program has also certified 637 Eligible Provider (EP) ambulatory EHRs for Stage 1 MU (2011 Edition) and 11 for Stage 2 (2014 Edition) criteria along with 284 Eligible Hospital (EH) inpatient EHRs for Stage 1 and 6 for Stage 2 (https://www.cchit.org/find-onc).

    Physicians and hospitals overwhelmed by the current total of 4,189 ambulatory and inpatient EHR products certified for MU Stage 1 and 2 on the ONC Certified Healthcare Product List (1,904 complete and 2,285 modular) should consider first examining the EHR products with dual CCHIT certification. These EHRs are tested by using both the more rigorous CCHIT Certified® testing criteria and the ONC-MU Stage 1 and 2 criteria.

    Right now, only 110 ambulatory EHRs and 15 inpatient EHRs have achieved dual CCHIT certification for 2011/2012 and no EHR has yet become dually certified for 2014 (https://www.cchit.org/find-onc) .

  2. Mike I agree with you that cost is most important factor in implementation of any product or system. But, it all depends upon vendor needs or requirements how that product satisfy or meet his requirements. One of the affordable EHR products which I found is Panacea. You can get more information about Panacea at http://www.oasite.com.

  3. But as soon as you include a list of required usability factors, it becomes just another checklist that may or may not actually mean anything beneficial to the end user. “Usable” to who? New check box, still not likely to be all that useful. The problem is that the vendors have been so focused on the check-boxes that they haven’t had time or resources for the stuff that’s actually more important to us docs. At least part of your point was that there are TOO MANY products – artificially limiting the choices in the market through regulatory burden will significantly raise the cost of healthcare because for the cost of complying to be a disincentive for participation by vendors, the cost will have to be very very high. I think one can make a strong argument that the reason there are “some vendors with crappy certified products…making millions of taxpayer funded dollars” is precisely because of too much government regulation, not too little. (Had I stayed in private practice primary care, there was no way I was going to attempt meaningful use stage II. The stage I money was nice, the stage II requirements too steep. The coming penalties for not complying are one of the many reasons I left private practice primary care, and part of why I am looking to leave primary care altogether. There is a very real cost to making participation in a profession a regulatory nightmare especially when that profession is essential to the health of a society.)

  4. Mitt, the point is that the government is certifying these products as useful in order to qualify for payments as well as avoid penalties. You sound like you would just as soon see the whole program go away – well I live in Realville and that is not happening any time soon. Healthcare providers can decide what products are good for them, but unfortunately they can only choose from a government approved list. I am saying that at the least the list should include some usability factors…

  5. These complications are true, as are the excess profits being earned by vendors hawking crappy products. My questions are still unanswered. Why are health care providers unable to decide what is a good product for them? If they are irrational or uninformed decision makers, then you must make an argument for how the CHPL will do a better job than thousands of providers making decisions in a market.

    Also, you’ve got a answer why this adverse reaction to government intervention in the EHR market is a reason for more government intervention?

  6. Both Mike and Mitt are missing my point. If government is going to regulate which EHR vendors are certified (as they are now doing) then that certification should be helpful to the market.
    The fact is that there are incentives already and penalties soon to be applied for healthcare providers using (or not) certified EHR technology. Some vendors with crappy certified products are making millions of taxpayer funded dollars, while the provider is left hanging out to dry. And now there is a proposal for user fees so that the customer will ultimately be forced to pay the certification costs as well…

  7. How exactly can you say there are “Way too many products” on the certified list. Isn’t it the job of providers, practices, and groups to decide what they buy? The assumption behind saying there are too many EHR products is that the CHPL knows a good EHR from a bad one. Solyndra anyone? Greentech Auto? Even if there is a lot of junk on the market, I’ll take the evolutionary process of entrepreneurship any day over the Frankenstein madness of central planning.

    And even if there is a lot of junk on the market, is it not true that lots of entrepreneurs in a space is a good sign of innovation? Why should a politically motivated CHPL be able to choose which companies to bless and dictate how many vendors are on the market?

  8. Do you not realize that thinning the ranks of vendors via regulation will result in increasingly greater expense to the health care system that will ultimately be passed down to patients? It is extremely likely imho that there is a price point at which the whole thing falls apart – the cost to implement HIT becomes greater than the penalty for not implementing HIT and then you are left with either imposing even greater penalties or watching all you have worked so hard for collapse under the regulatory burden. Actually both of those outcomes are likely .

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