Current and Future Payer and Industry Needs Solved by Certification of EHRs
Providing Americans with high-quality, safe, affordable healthcare is behind the national push to use health information technology (HIT). In response to this increasing and ever more acute challenge, the Department of Health and Human Services established four goals as part of its framework for strategic action of 2004:
- Inform clinical practice;
- Interconnect clinicians;
- Personalize care; and
- Improve public health.
These goals have profound implications for our healthcare industry. It is anticipated that the deployment of the required technology to meet these goals will impact how physicians are paid and the type of information patients have access to, not to mention new hardware, software, intermediaries and other industry changes. However, all of the complexities and challenges of making these goals a reality distill into one significant underlying interaction: a patient and a physician seeking to improve health status.With this as our organizing principle and ultimate unit of measure, a clear set of actions emerges.
Steps Toward a National Health Information Network
Electronic health records (EHRs) are the central foundation for all subsequent systems, whether financial, clinical, research or administrative. EHRs are the anticipated technical foundation for the patient-physician interaction. Therefore, these systems must achieve the highest level of security, functionality, interoperability and data completeness. These systems face a tall order: maximizing the safety, health and effective care of patients while satisfying a very demanding and challenging end user physicians. Creating such a system, however, is further complicated by our current environment of multiple, disparate systems with incomplete clinical and technical standards for deployment, poorly understood impact on workflow, user interface design challenges and multiple custom interfaces required for interoperability.
Definition and Role of Product Certification
Given the requirements of software development cycles, financial requirements and adoption periods, we must create a road map that spans several years. This road map must include objective criteria that grow in depth and breadth until the vision of a broadly deployed, value-adding EHR is realized. The road maps criteria must include a pass/fail metric as well as an objective, trusted party that can vouch for the accuracy of the certification results. Self-attestation by the vendor may be acceptable for select, obvious components of the software as well as certain steps in the recertification of products (such as a capability that was present and certified in the previous year for which no modifications to the standard or software have been made in the intervening time period). However, objective, testable criteria that are focused on real needs for real users must be the basis for the majority of the certifying process.
The certification of EHRs has a central role in the national effort to increase the availability, deployment, use and refinement of them. It is the most compelling strategy for realizing the vision and ensuring an objective measurement on the industrys or a vendors progress in achieving this vision. A compelling certification provides an objective standard that all stakeholders in the healthcare value chain (hospitals, health plans, physicians and patients) can point to with confidence regarding the validity and accuracy of the anticipated system capabilities. This function will be required in order for health plans to play an effective role in this evolution of the healthcare industry.
Role of Health Plans in Driving Health IT Enabled Through Certification
Although there is still much uncertainty as to how HIT will be deployed, there are several potential points of leverage that a health plan can provide in driving HIT solutions. These include:
Accelerating Adoption Through Use of Plan-Based Clinical Data Sets
A substantial challenge in the deployment of HIT is the conversion from a paper to an electronic environment. Today physicians must operate in a mixed electronic-paper environment for prolonged periods of time or the health system must pay for substantial paper-to-electronic conversion projects. Health plans can play an important role in this conversion by offering the ability to prepopulate EHRs with a base set of clinical data derived from claims data sets available on broad sets of patients. These data sets can include ICD-9 codes for diagnosis, CPT codes for procedural information and NDC codes for prescribed drug information.
Some health plans have lab data sets developed through HEDIS measure generation. These data sets provide an opportunity to deliver value for both patients and physicians from the moment an EHR goes live. However, health plans are unlikely to provide this data to environments where there is significant potential for inappropriate use, security or privacy breaches. Therefore, an EHR, certified for acceptable levels of security, will likely need to be present to access these value sets. A strong and industryaccepted certification process will enable this data delivery.
Accelerating Adoption Through Payment Incentives
Although HIT is expected to provide a positive return on investment, it requires substantial upfront capital and a meaningful product/network strategy to recoup these investments (both financial and clinical). Further, the current payment strategy provides challenges for hospitals and physicians that currently deploy systems to improve clinical performance. Fee-for-service medicine can potentially reward inefficiency and poor outcomes more than efficient, high-quality practices. This is because complications result in the need for more medical services which, in turn, result in greater payments to the physician. Pay for performance is a tool that can help resolve this issue by rewarding physicians for improved outcomes. Its utility is enhanced by the use of HIT and clinical decision support, both which drive improved adherence to evidence-based medicine. Strategies that have been promoted include direct payment for use of e-health technologies and payment for the process and outcome measures that leverage data sets generated by these technologies. Regardless of the strategy employed, a standard set of criteria and a publicly available certification process will be required.
Improving the Value Measurement of HIT
Health plans, clinical researchers, actuarial and other professions and industries interested in tracking healthcare expenditures need to understand the unique value that HIT provides. The measurement of this value in an incremental fashion will be critical in attracting ongoing investments to broaden system deployments, justifying system modifications to maximize ROI and supporting ongoing system improvements. Yet value measurement and quantification will be challenging. Among these challenges are risk adjustment, confounding variables such as benefit design changes, ongoing turnover at physician practices and a plethora of e-health record capabilities currently on the market. These challenges will require clinical trials similar to what a medical device might be put through in order to track efficacy and effectiveness. Standardizing a minimum functionality set reduces the variability of the effectiveness of the interventional group so that more compelling measures of value can be obtained.Without certification physicians who use glorified word processing tools or spreadsheets may be included in the analysis and reduce the refinement of the study.
Product certification of HIT products, including EHRs, is a needed and important requirement in the deployment of technology for use by physicians, patients and others in the healthcare industry. Organizations such as the Certifying Commission on Health Information Technology should be encouraged to rapidly deploy and make available a certification process for vendors seeking to deploy HIT solutions. The certification process is a central wheel in turning the industry toward greater use of technology.
