US building momentum by accrediting health IT

Accreditation of vendor applications, based on core interoperability standards, is helping to spur adoption of ICT within the United States of America healthcare system.

Initial results suggest the accreditation of electronic patient record systems is leading to financial incentives for their adoption, and helping drive spread of key functionality such as order communications.

Speaking at World of Healthcare IT in Vienna, Dr Mark Leavitt described the approach and progress of the Certification Commission for Healthcare Information Technology (CCHIT), the federally-funded organisation he chairs.

“Every time I travel I feel bad that America is so far behind,” Dr Leavitt told the largely European audience in Vienna. “The level of health IT funding in US is miniscule in comparison to overall health funding. In the US government does not buy health IT systems.”

Instead, he said that the government is trying “to do a few things and catalyse adoption of health IT”. One of them being to accredit vendor systems to a core set of requirements that healthcare funders and providers can have confidence in.

“Our mission is simply to accelerate the adoption of health ICT – make sure the technology is interoperable and robust,” said Dr Leavitt.

Founded by organisations including HIMSS (Healthcare Information and Management Systems Society) and the American Healthcare Information Management Association (AHIMA), CCHIT won a £7.5m contract from the Federal government in October 2005. Initial certification work focused on ambulatory electronic patient record (EPR) systems, with work now underway on inpatient EPRs.

So far, CCHIT has agreed a set of foundation criteria that apply to ambulatory and inpatient, together with criteria for specialist systems such as children’s. “From next year we will start certifying emergency and the networks that will link these systems, such as state or private networks,” said Dr Leavitt.

He outlined the value of certification: “I believe certification can reduce risk, make systems more compatible and interoperable, making it easier for payors to provide assistance and relief. And it can also lead to improved patient safety.”

CCHIT has ten groups averaging 10 -18 per group working on agreeing standards. Most of the work is done by virtual telephone and web conference to keep costs down and ensure momentum. Dr Leavitt described the approach as “consensus based”.

Vendor systems are inspected and judged on three criteria: their functionality, how secure they are, and whether they are interoperable.

The evaluation work is carried out at three levels. “One method is to ask vendors to send some documentation. The next is a jury observed demonstration, and that has proved very successful for us”. The most sophisticated level is purely technical

“For functionality we use observed. For security we use documentation and observed. And for interoperability is both demonstration and technical tests,” said the CCHIT chair.

“Jury observed demonstration is done virtually with three jurors who watch according to a careful script, with demonstration done by a proctor who manages process carefully.” The observation process typically takes half to a full day. If a supplier can’t do it within four days they are ruled out.

Dr Leavitt explained CCHIT has failsafe mechanisms so vendors get a second chance to show they can meet requirements, “we will then bring in a second jury to ensure it’s not bias.”

On interoperability CCHIT has moved quickly from documentation to testing, collaborating with the MITRE Corporation (a non-profit Fed Research and development centre)

“We will develop this all under open source so a vendor can get tool and test as much they want. We’ll have more information on this in the next couple of weeks. Kicking off an open source development effort,” added Dr Leavitt

The criteria for ambulatory EPRS have risen to 250 criteria this year, up from 150 last year. In inpatient 2007 got 191 criteria – including a requirement for order communications. “We require vendors to provide 100% compliance,” stressed Dr Leavitt

CCHIT has two boards, one on finance and one on certification, and have staff then work groups made up of volunteers, and in such a way have 20 staff leading 200 volunteers.

“We are an independent group in the private sector. We don’t automatically have trust, we have to earn that. We publish everything we do, including interim work and we do a lot of outreach work.”

He said that after a frenetic first year CCHIT has now established its blueprint for future work. “We have settled down into a one year cycle. First is to do an environmental scan, then a first and second draft of criteria, then a pilot test script, publish draft of criteria then publish final draft and start certifying.

“One of best things we have done is set out a road map to the future so the industry knows what to expect over the coming year or two.”

He said that after a year CCHIT was beginning to see market acceptance for its approach. “We have widespread endorsement from physician professional orgs and among vendors.”

Of an estimated 200 ambulatory EHR vendors in the market “40% came to us in first year, accounting for 75% of EHRs in use”, said Dr Leavitt. “In the hospital area we are off to a good start, we think there are about 25 and we had six in the first batch.”

He added that one of the main concerns – that certification would drive out smaller suppliers – had not occurred. “We’ve surveyed them and three-quarters have revenues of less than 10m – there is no evidence we have created a bias.”

Among the benefits are “a number of financial incentives” coming through for adoption of accredited EPR systems: “We have seen 5% discounts for malpractice premiums”.

Next steps planned are to continue to build the requirements for ambulatory and inpatient EPRs – such as the requirement for all hospital systems to provide order communications. Further ahead agreed plans cover child health and cardiology. “In future years would plan to add behavioural and long-term care,” said the CCHIT boss.

Jon Hoeksma