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Response to My Friend Joe re: Certification

by Wes Rishel  |  July 31, 2009  |  3 Comments

Joe Heyman wrote a response to Practical Concerns re: Certification Recommendation that raised some important points. A dialogue between us may further illuminate the points.

I don’t know if Joe meant to imply that I am advocating CCHIT as the sole certifier, but let’s be clear up front that I am not. My concern is with the provision of the recommendation that implies that only the vendor gets to choose which certifying agency they use.

On to specifics. Joe writes:

There are competing accrediting organizations with the Joint Commission. It is the most difficult, not the cheapest, and, yet, the most popular.

This actually goes to the heart of my concern.  The Joint Commission is actually chosen because CMS and other payers require that it be used. If the agency that makes a decision to pay based on accreditation chooses the body that does it, then I would have no qualms about competitive accrediting agencies.  [Please see note added on 1 August.] However the recommendation of the Policy Committee effectively prevents this by saying that a vendor should not ever have to get more than one certification.

Arguably, if physicians could chose the certifying organization they would not pick the one with weakest accreditation. After all, they have to live with and use the product. But under the “any certifying organization will do” approach, this is not the option that will be presented to physicians.  They will be asked to choose among products each of which is rated by several organizations, some of which are focused on the baseline requirements for certification and others of which use any number of criteria for judging products. Many of them like KLAS and professional societies have so far focused on polls of user satisfaction. This is good, those are also important ways to pick products but assuring user satisfaction is not equivalent to ensuring that society gets the benefits.

Joe further writes

I think Wes’ is looking for the dark side of people. His argument that, “It is unlikely that the majority of physicians will accept these features unless they see near-term, highly credible pain if they don’t”, speaks to that attitude. That is a terrible description of why physicians do what they do.

The truth is just the opposite and actually is the problem: It is unlikely that the majority of physicians will accept these features unless they see near-term highly credible benefit if they do!

If they don’t see that benefit, then why should they purchase something? To satisfy someone else’s needs?

Of course the rhetoric about “the dark side of people” is inherently unanswerable. The rest of his comment, however, is very much focused on the heart of this issue. Why is the government spending all this money to create incentives for EHR adoption? Arguably it is exactly to satisfy the needs of someone other than the physicians.  Everyone would agree that physicians want to have help giving better care but there is considerable reason to believe that they don’t want to pass data to measurement agencies and be subject to the very imprecise measures of quality being proposed at this time. But if Obama’s statement that the EHR incentives are a “down payment on healthcare reform” are to be taken seriously one must believe that there are indeed features of EHRs that physicians don’t find personally useful that nonetheless drive the incentives.

One one point we agree: physicians should not be purchasing EHRs unless they find the systems personally useful.The incentives are not big enough to justify any other reason for purchase. However, given a field of EHR choices, one can hope that the incentives may steer the physicians to physicians that also support the external quality initiatives associated with healthcare reform.  As with all policy initiatives these will be blunt objects. They are not features that physicians will find personally useful.

Finally, Joe asks:

Have we any evidence whatsoever that CCHIT certification has improved quality and safety for anybody?

I am not aware of any studies that either confirm or deny the value of CCHIT certification. However, I would urge readers to look back at what I wrote in the original post about the impact of CCHIT certification on clarifying that “scan and file” document managing systems, probably don’t reserve public financing through Stark Relief or the incentives, even though some physicians will find them personally useful.

(Note: some readers will say that in comparing TJC to certifying organizations Joe and I have  conflated two different things. While this is technically correct, I don’t believe it weakens the value of the comparison.)

(Additional note entered on 1 August. ) As Joe points out, CMS authorized a second certifying agency this year. the first new one in 29 years. It is far too early to tell, however, if this supports Joe’s assertion that competition among certifying organizaitons increases does not generate a “race to the bottom.”




Wes Rishel
VP Distinguished Analyst
12 years at Gartner
45 years IT industry

Wes Rishel is a vice president and distinguished analyst in Gartner's healthcare provider research practice. He covers electronic medical records, interoperability, health information exchanges and the underlying technologies of healthcare IT, including application integration and standards. Read Full Bio

Thoughts on Response to My Friend Joe re: Certification

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  2. Joe Heyman says:

    Wes, et al,

    There are three private accreditation programs for hospitals, and other health care organizations. They are AOA, DNV and the Joint Commission. Hospitals may also be accredited by their state departments of health. The hospitals get to choose which of those entities they wish to use without interference, but they must be accredited by one of the four in order to receive Medicare payments.

    The overwhelming majority choose the most difficult accreditation entity because of the pride associated with having the gold seal of TJC.

    My concern with CCHIT is that there are so many requirements that most physicians don’t need in their technology to run their offices and probe their own data, that it makes the technology more expensive, makes all the programs similar and may suppress innovation.

    My personal opinion is that HHS certification should go no further than insuring the criteria for “meaningful use” set by ONC. That gives vendors a chance to innovate around those criteria. It may well be that new products that don’t remotely look like EMRs may develop and satisfy those criteria.

    If CCHIT or others want more criteria beyond HHS certification (as the Joint Commission has beyond those of CMS), then that may become a goild seal for which future vendors may compete.

    Now, let me say that I am on the board of the AMA and also on the Certification/Adoption workgroup for the HIT Policy Committee and the views I express here are only my own.

    And, Wes, you are my friend!


  3. Joe Heyman says:

    I meant “assuring the criteria for meaningful use”. Pardon my grammar.


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