By John Carruthers, staff writer, June 01, 2011
With penalties looming in 2015 and “meaningful use” incentive payments for adoption available from Medicare and Medicaid, many dermatologists are taking a new look at the market for electronic health records (EHRs). They face a marketplace in which many systems are certified to meet the government’s meaningful use requirements and allow them to earn bonus payments — but only three have undergone the process of being certified to meet the needs of dermatologists. What should dermatologists look for? According to dermatologists who have been involved in the development of certification requirements for the specialty and a practice management consultant who works with dermatologists, choosing a system that can meet a dermatologist’s specific needs requires careful, hands-on research, particularly in light of changes to the certification process in the last year. But with a handy checklist of features to look for and a willingness to shop around, dermatologists can make an educated choice that will serve their needs and allow them to earn incentive payments and avoid future penalties.
Certification and meaningful use defined
The financial incentives offered by the Centers for Medicare and Medicaid Services (CMS) for practices that meet requirements for the “meaningful use” of EHR systems require physicians to adopt an EHR system certified for meaningful use and utilize it to meet a set of CMS-defined objectives for an extended period. These meaningful use objectives are the baseline requirements that practices must meet to qualify for incentive payments. (A list of the 15 required objectives and a menu from which meaningful users must select five more objectives to complete is available at www.aad.org/hitkit.) For physicians who decide to commit to EHR in 2011 or 2012, these payments can total $44,000 over five years if you participate with Medicare, or up to $63,750 over six years if you participate with Medicaid. This potential financial incentive, according to practice management consultant Margret Amatayakul, underscores the importance of meaningful use certification. EHR systems that can be used to earn meaningful use incentives receive certification from an Authorized Testing and Certification Body approved by the Office of the National Coordinator and are designated by an ONC-ATCB seal (see sidebar). [pagebreak]
However, not all products certified for meaningful use are necessarily the optimal choice for dermatology practices.
“I think the most important thing for dermatologists is to be sure the products they are looking at are both certified for meaningful use and meet the criteria [that ensure they will be useful for dermatologists],” Amatayakul said. (See sidebar for a list of criteria to consider.) “Just because a product is certified for meaningful use doesn’t mean it incorporates every function that may be desired,” she said “In fact, the government acknowledges this in the preamble to the regulations.”
One way to assess whether a product is useful for dermatologists is to look for dermatology-specific certification from the Certification Committee for Healthcare Information Technology (CCHIT). As recently as 2010 CCHIT was the only body certifying EHR systems and well-known in the industry for
its rigor. The independent nonprofit organization, created in 2004, began certifying EHR technology two years later, and began offering a dermatology-specific certification, based on criteria developed by a work group of dermatologists, for 2011. [pagebreak]
But while CCHIT is the only body offering dermatology-specific certification, it isn’t the only one approved by the Office of the National Coordinator to certify products for meaningful use and award the ONC-ATCB seal. In 2010 the ONC re-launched the EHR certification program in conjunction with the development of meaningful use incentives and opened up the process to new organizations, creating the Authorized Testing and Certification Bodies (ONC-ATCBs) certification category. Today CCHIT is one of six ONC-ATCBs that have certified more than 400 EHR systems as qualifying for meaningful use incentives. (An up-to-date list of systems that can be used to earn meaningful use incentives is available at http://onc-chpl.force.com/ehrcert. See sidebar for a list of certifying bodies.)
As a result of the changes, and the emphasis on meaningful-use certification over certifying products for specialties, only three EHR systems have qualified for CCHIT’s dermatology-specific certification (see sidebar for more information), according to dermatologist Mark Kaufmann, MD, who chairs the EHR demonstration sessions at the Academy’s Annual and summer meetings and serves on the advisory board of Modernizing Medicine.
“As you might imagine, there are fewer people going for the rigorous CCHIT certification because they don’t have to,” Dr. Kaufmann said. “There are three derm-certified systems — NextGen, NexTech, and VersaSuite — out of more than 400 systems that are certified for meaningful use.” But, as AAD President-elect Daniel M. Siegel, MD, who consults for software makers Ensight and DermFirst, points out, some of the remaining 400 systems may well meet a dermatology practice’s needs. “There are programs that are derm-functional, but don’t get the derm certification because they would have to spend more money on that.” (To read more about how CCHIT certification for dermatology was developed, see sidebar.) [pagebreak]
Choosing a system
With many vendors forgoing dermatology certification, dermatologists need to do some digging if they want to look beyond the three CCHIT-Dermatology certified vendors.
In choosing a system, it’s important to plan for as much hands-on experience as possible, according to Dr. Kaufmann. The EHR demonstration session at the Annual Meeting, which usually attracts capacity crowds, allows physicians a hands-on demonstration of current EHR software by their colleagues, rather than vendors. Afterwards, he said, many physicians feel far more comfortable exploring the marketplace.
“During the demonstrations, we get anywhere from four to six physicians to demonstrate their use of their EHR. They give the good, bad, and ugly of each of their systems. I think that would be a really great way to get your feet wet [for physicians] without EHR experience,” Dr. Kaufmann said. “For those people who are a little savvier, I’d encourage them to see a demo from a vendor, but not rely on a vendor for the decision. They do this all day, so it’s important to take it with a grain of salt. The most important advice that I can give anyone is to go visit a physician who is using a product live and ask if you can just follow them around for an hour or two. Just to see what it’s like to use the system in a live environment. It’s always going to be a little different to see someone using the system in a completely unpredictable way.” [pagebreak]
Dr. Siegel agreed that seeing a colleague demonstrate EHR use would offer those considering a purchase the best sense of what might work for them. For physicians who may be unable to utilize that option, he said, there are a number of options to gauge a system’s suitability for their practice. Many vendors offer in-practice demonstrations that give the physician an idea of how the system and its features would integrate into their practice. Further, larger vendors will be able to point one to successful adopters nearby who will be able to discuss the features and functionality of a system with them on the level of a colleague without the necessity of an all-day visit. Speaking with a physician, he said, can often give one an idea of how intuitive the EHR interface is — often a sticking point with new adopters.
“The problem is that with many of the text-based systems, there seems to be a lot of fumbling. Things don’t always seem intuitive,” Dr. Siegel said. “What is intuitive to some people may not be for others. There’s great variation on this. The problem is how you tell them what [choices are] out there. Hopefully, with the demo, a physician can look up and say the logic of this is something that works for me,’” Dr. Siegel said.
When choosing a system, Amatayakul, who has herself participated in past EHR demonstrations at Academy meetings, said that it’s vital for the physician to negotiate not just for a better financial deal, but for help in training and implementation. In addition to training staff on capturing meaningful use data, additional training can create a much better EHR transition, which will ultimately prove healthier for the practice. [pagebreak]
“Physicians need to negotiate, negotiate, negotiate the contract. Every contract is negotiable, but price is not the only thing to negotiate,” Amatayakul said. The schedule of payments for the system is potentially more important for dermatologists to negotiate, she said, and noted that with so many physicians trying to become meaningful users in order to earn incentive payments, “vendors will be strapped to do good implementations,” and dermatologists should be sure they carefully scrutinize the level of implementation support, training, and go-live assistance included in their contracts.
Awaiting the future
Dr. Siegel said that physicians experiencing anxiety over the inability to choose a program should remember that waiting, while a progressively less-discussed option, also remains on the table, and he continues to see enhancements from a variety of vendors.
“I’m gung-ho about seeing EHRs truly work. The bar is being raised quite a bit in terms of image-based functionality and intuitive navigation. I can’t imagine the larger players not continuing to evolve,” Dr. Siegel said. “They’re going to have to try to be better. Everyone wants to have the best features. And by definition, if you’ve got something new that works, you’re in the lead. It will be interesting to see what happens. If I hadn’t yet converted, I might be tempted to wait for about a year.”
The window to wait a year and still earn meaningful use incentives remains open for the moment. Physicians only have to attest to meaningful use for the last three months of their first year on the program. Physicians who are able to get their practices up and running on a certified EHR system before October of 2012 can still receive the maximum incentive amount. [pagebreak]
Dr. Siegel’s belief in the ability of the EHR marketplace to grow and advance is supported by the remarkably rapid advances in both the hardware and software.
“We’ve watched a lot of things change. When we first started down this road, all the software was server-based. You had to buy a server and have it in your office. Now, even the server-based vendors have options where you can use software as a service and work in the cloud,” Dr. Siegel said. “Now, all you need is a good connection to the Internet, rather than a large investment in infrastructure. Someone coming out of residency who wants to go digital can make use of an option where they can get software as a service and a wireless router with security features — and be up and running within hours. It’s very impressive.”
Checklist of features
Before approaching a vendor, it’s important to consider the features that best serve one’s practice. Many Academy members participated in the development of the CCHIT criteria for dermatology-specific certification, the only dermatology-specific certification on the market. These features include:
- The ability to capture the characteristics of a lesion as discrete data fields, including color, size, shape, arrangement, distribution, type, scale, and signs.
- The ability to annotate body diagrams and photos with text, as well as the ability to draw on them.
- The ability to create a log with statuses of dermatologic specimens removed from the time of the removal through final action by the dermatologist without duplicate entry.
- Free-hand diagrams for each patient encounter.
- The ability to compare two photos on one screen.
- A library of cutaneous anatomic diagrams to select from.
- Exportation of Maintenance of Certification data.
Amatayakul and Drs. Siegel and Kaufmann also recommended that dermatologists evaluate systems based on the following criteria:
- Inventory management
- E&M coding assistance
- Billing and scheduling interface
- Integrated e-prescribing
- Automatic refill requests
- Medication history
- Clinical charting
- Drug and allergy alerts
- Electronic billing
- Lab orders, results, history, and management
- Surgical templates
When browsing a vendor’s website or marketing materials, it’s important to look for certification seals to ensure the product qualifies for government incentives. The CCHIT + Dermatology seal signifies an ambulatory product with dermatology features that satisfies CCHIT’s rigorous standards. (All three currently certified systems are also ONC-ATCB certified.) The ONC-ATCB seal denotes products that have been certified by one of the six ONC-ATCB organizations (see below) as qualifying for meaningful use.
Dermatology, meaningful use, and CCHIT certification
Prior to the creation of additional certifying bodies, Mark Kaufmann, MD, chaired CCHIT’s workgroup on dermatology certification. His experiences help illuminate why dermatology-specific EHRs remain an extremely small sector of the marketplace.
“It goes back to CCHIT’s original marching orders. During the previous administration, they were the only game in town the only body that was certified by the Department of Health and Human Services to certify EHRs. This was before meaningful use. When the AAD got involved trying to get them to hear our complaints, they heard them and said You have a point. Why don’t we put together a work group and create a derm certification?’ “Dr. Kaufmann said. “I co-chaired that work group, and we worked for six months on developing criteria that addressed our concerns about the way they tested the vendors. We came up with a lot of criteria related to photography, graphics, and being able to put photos side by side. [See sidebar, p. 36, for a list of criteria.] They were all things that we wanted in our systems that weren’t being addressed at the time by CCHIT. In the end, it was great, they accepted all of our criteria, and it was all looking really good. Then, all of the sudden, meaningful use came out. So what happened?”
Increased government focus on these mandated quality measures, according to Dr. Kaufmann, took the focus away from EHR vendors addressing specialties and placed it mostly on satisfying meaningful use. The result is a marginalization of CCHIT certification, he said, due to the existence of six certifying bodies instead of one and the way certification in dermatology is structured.
“CCHIT decided not to make [certification for dermatology] just a straight derm certification, but rather an add-on certification for ambulatory,” Dr. Kaufmann said. “So what that means is that you had to pass all the other ambulatory requirements before you could pass certification for dermatology as an add-on. It would always be ambulatory plus derm,” he said. Academy President-elect Daniel M. Siegel, MD, agreed. “The important point to make is that CCHIT or other [ONC-ATCB] certifications are important to get [meaningful use] money back for the user, but all CCHIT certification for derm does is operate like a subspecialty add-on. It doesn’t mean that you’re getting rid of the extraneous stuff that we don’t use, it just means that there are image capture and other features that we use. It’s an important distinction,” Dr. Siegel said. “There are programs that are derm-functional, but don’t get the derm certification because they would have to spend more money on that. And having it doesn’t necessarily mean that it’s user-friendly.”