By Matthew Holt
There’s been a lot of blather from one commenter (who may or may not be a front for a group of malcontents) on the WSJ Health Blog and lots of other blogs about CCHIT and whether it was doing business without a license in Chicago, and/or was a front organization for HIMSS or EHRA. All summarized on Neil Versel’s blog. Indeed I did get a call from one well known blogger telling me that HIMSS’ lawyers had asked for him to take those comments down—not too bright a piece of PR on HIMSS’ part IMHO.
MrHISTalk thankfully did what I certainly could not be bothered to and actually looked into the “CCHIT is not a licensed corporation” situation and figured out that it’s basically being run legitimately. I myself cracked the joke privately that if CCHIT/HIMSS/EHVRA/Leavitt et al had only managed to get $2m (or $7m for that matter) out of the Bush Administration, they needed to go to the Haliburton school of “how to stick it to the taxpayer properly.”
The other wisecrack I’ve heard is that the way to determine the list of functions an EMR needs to have to get CCHIT certified was to copy the feature set of Allscripts TouchWorks. (Of course you can insert the name of any of the other big EMR vendors here too).
OK, so we’re kidding around here, but underneath this discussion are some serious points. And those serious points have got little to do with what has indeed been a pretty close relationship between the powers that be at HIMSS,EH(V)RA, CCHIT & HITSP.
In any case I assure you that the back room dealings and conflicts of interest are nothing compared to how the rest of the Federal government has colluded with industries it regulates for the last 8 years. The money given from ONC to CCHIT wouldn’t even be a rounding error on what’s been completely lost in Iraq in cash in suitcases. let alone what Blackwater, Halliburton et al have stolen, And there’s no evidence that the Feds didn’t get what they/we paid for from CCHIT, which is a certification process.
So if this is a non-story, what are the actual issues?
1) Part of the justification for a certification process is that there is a great deal of fear and trepidation among physicians who have heard the horror stories about EMR implementations, and are now being bribed (and later to be threatened) by the Federal government into installing EMRs. Given the plethora of vendors out there, and the fact that these providers are more or less Federal contractors who tend not to understand IT, it’s not unreasonable to suggest that the Federal government (or someone) gives authoritative guidance as to what’s a robust system that has the right features and functions. Remember that the nation’s biggest and richest integrated provider organization trashed not one, but two national investments in EMRs before getting it right at try three. Having recalled that it becomes reasonable to agree that most providers need some help. And of course there is some slight protection for the taxpayer if the providers who are about to get their $40K have to do more than just claim that they bought an EMR from Sonny on the corner.
2) Of course once you say that the Federal government will pay out only to those purchasing certified products you then run into two other problems. First, the certification process is going to get somewhat politicized. Despite all the yakking about “volunteers” on all these committees, what we’re talking about is the people with a deep interest in EMRs et al being those “volunteers” and of course they are mostly from the vendor side or users who know the vendors well. I don’t see a way around that unless we really want to develop a civil service that has expertise in health care IT and also is prepared to stay in the job for 30 years like they do in Japan. Second, by its very nature the certification process is likely to run behind the development of technology, which means that vendors building for the certification process are like teachers prepping students for tests, not creating innovations. Again that may not be a terrible thing, but it’s not how innovation works in most other industries. (John Moors at Chilmark has a rather blunter, bleaker assessment of how this might work out)
3) And of course, the reason that you don’t see Federal certification of, say, MP3 players or automobiles is that there’s a somewhat effective market there that means that innovation and user experience gets rewarded. Make a confusing MP3 player, you don’t move the needle much. Figure out how to make it easy and elegant and you’re called Steve Jobs and you sell a gazillion iPods a year. Health care doesn’t have such a market, or even rationally managed incentives from its Federal paymaster.
So I don’t have the answer, but I do have the question. And it’s the same one being posed by the Dogs, in response to the Cats. Can we realistically expect CMS and the rest of the big payers to start rewarding providers for producing the correct outcomes. If we paid for outcomes, providers would change their organizational structure, and their processes, and the technology they use. The ones that worked would succeed and the others would go away. That’s how a market works. And that would create lots of interesting technological innovation of the type that is already happening in the consumer health arena in Health 2.0.
But (beware: run-on sentence coming up so take a deep breath) if we realistically can’t get to some massively enhanced version of pay for performance very soon, and instead are going to insist that providers use EMRs or something like them and the Feds will pay them for it, and we are happy to declare that that solution is as good as we’re going to get while we work on wider health system reform later, then I don’t think that we can complain about the CCHIT process too much. We have to accept that the Feds are going to put a stake in the ground somewhere as to what is an acceptable technology to reward. And those rewards are not going to be market or outcomes-based yet.
So the ultimate question, is what’s the time-scale for junking our stupid current health care incentives and finance system? And the answer is, not in the next 2–3 years.
Which means that if we’re paying directly for technology (which we are as the law is now passed), a certification process is a necessary evil to help providers and to make sure that the tax payer isn’t being defrauded (see we’re back to Iraq again!).
Of course, this doesn’t mean that the certifiers shouldn’t be made to appear to be (as we;; as actually be) completely above board and be watched like hawks to make sure that they’re not putting too many restrictions on smaller companies or discriminating against them. And maybe that kind of oversight demands that we see greater separation between the HIMSS/EHRA/CCHIT/HITSP/ AHIMA players, which would fit in with Obama’s “no lobbyists in the Administration” line.
But I can’t see that this is an issue for anyone to go to the barricades about. And in the end if CCHIT helps providers get better tools than they have now, it’s probably a net positive—even if it may prevent greater innovation happening faster.