Fred Trotter

A few months ago, CCHIT suffered from what I like to call “angry letter round 1″.

This is were I send a very pointed, ultimatum letter to an organization of the general form “your are hurting my community, stop it or else”. Personally I find that about %50 of organizations respond positively and about %50 do not.

I am happy to say that Mark, Dennis and the other members of the CCHIT team have won my respect and appreciation with how they have taken a 90 degree turn from being an organization that was largely ignorant regarding the health FOSS movement to one that listened and engaged carefully, and has now come back with a plan for certification that I personally, and from what I can tell the FOSS community generally, can embrace.

This post is me doing that. At this stage I am comfortable recommending (to whoever is making the decision) that CCHIT be allowed to be one organization allowed to certify for ARRA funding, under their new EHR-C/EHR-M/EHR-S certification model.

Specifically, I am talking about the new site level certification program. Here is a cut and paste from the CCHIT townhall pdf regarding EHR-S site certification.

Certification Program Concepts for EHR Sites (EHR-S)

• Definition: Certified EHR-S sites have developed or assembled EHR technologies that comply with Federal standards and enable them to meet all Meaningful Use Objectives.
• Provider applicability: Any physician office, clinic, hospital, other facility or network that has self-developed or assembled an EHR from various sources and wishes to apply to ARRA incentives.
• Certification requirements: Functionality available (regardless of deployment model) that enables providers to comply with applicable Federal standards, implement adequate security practices, and meet Meaningful Use Objectives.
• Inspection methods: Virtual Site Visit technology with offline inspector review and follow-up correspondence.
• Cost range: ~$150 – 300 per licensed provider (ambulatory); hospital pricing model TBD. Scholarships for eligible providers (FQHC, underserved population, critical access, etc) if grants can be obtained.

This along with the fact that all of the new certification programs will not require re-certification for minor software revisions, means that there is a clear path for FOSS adoption along with ARRA funding assuming CCHIT certification is endorsed.

Of course, as Dr. Billings points out, there are a lot of details to work out. However, unlike other critics of CCHIT, I have never felt CCHIT to  be duplicitous, rather they were one of the many groups who were trapped in a way of thinking that I disagree with.  Now that CCHIT understands how our community frames the EHR problem, they have done a good job creating a certification that can work for us.

This is a huge relief. I was afraid that our small community 501c3 Liberty Health Software Foundation, (LibertyHSF)was going to need to learn how to certify, create a standard to certify against and then get ourselves approved by the ARRA powers before the end of the year. Not good.

I would like to thank the FOSS community members who helped make this possible, especially Dennis Wilson, who served as a bridge between us and CCHIT. Thanks to Mark and everyone else at CCHIT who made such drastic rethinking of your core business in such a short time, we appreciate it!

I am now serving in the role as the director of LibertyHSF, and I need to start being careful to note that this is my personal opinion, and not the official opinion of LibertyHSF. I think LibertyHSF will probably have the same position, but I need to have a community vote on that before we will put something up on libertyhsf.org. That process takes a little more time to arrange. Still I personally have been one of the most vocal critics of CCHIT on this blog and I thought it appropriate to note that I approve of CCHIT’s most recent actions. (UPDATE 7-13-09 CCHIT has blogged about this post)

Regards,

-FT

If you have not heard of Paul Levy yet, then you are obviously new to the world of Health IT blogging. This is a CEO of a major Boston hospital that has commited to blog about his day to day dealings as the top administrator of a hospital. I have already gained many fundamental insights from reading his regular blog. He also sometimes blogs at THCB, which I follow.

Recently, he blogged about something off-topic for his typical subject. He blogged about infrastructure, specifically his efforts to get a road fixed. Here is the original post, but I am borrowing the relevant parts here.

A faculty member had complained to him that a bridge she used to get to work was covered in potholes:

Actually, I knew that I could do nothing, at least within a normal human lifespan. That bridge is a jurisdictional nightmare. It is at the border of two municipalities (Boston and Brookline), spans a transit line (MBTA), and also goes over a state park (owned at that time by the Metropolitan District Commission). Just figuring out who would be responsible for the road paving would take decades, much less getting the right person to order a repair.

So, I called Rick Shea, who was the President of MASCO, our non-profit planning and service entity for the schools and hospitals in the Longwood Area. The next day, Connie called to thank me for getting the potholes filled and a new, smooth surface on the bridge. “My pleasure,” I replied, wondering what happened.

I called Rick and he said, “I knew it would be impossible to find someone of authority to make this repair, so I just hired an asphalt firm and had the work done. Each jurisdiction — if they noticed — probably thought it was the responsibility of another. Therefore, no complaints. Job accomplished. Happy to help.”

This is ironic because this exactly what I believe Open Source software can do for Healthcare generally. By providing low-cost, excellent software, we can ‘just fix’ major problems in Healthcare that are intractable otherwise. Not that this ‘hack’ has two components: It was a technological/deployment issue of actually paving the road, along with the political insight that the mere deployment of the technology would work in the given political environment.

Here are a few things that are mired in power struggles just like this bridge.

• Quality – how to measure if a doctor is doing a good job, and to help him/her to be a better doctor.
• Patient empowerment – how to make a reactive patient into a proactive patient.
• Interoperability – how to get healthcare data to usefully move.
• Continuity of care – how to ensure that the ‘ball is not dropped’ as the patient moves around in the healthcare system.

-FT

Recently CCHIT has come under fire for being too focused on large proprietary vendors and specifically, its association with HIMSS.

These attacks have gotten so bad that Mark Leavitt has posted a rebuttal, which has generated a tremendous amount of attention over at THCB ( a blog well worth adding to your RSS feed)

Mark raises several good points in defence of his organization, including:

• There is currently no financial relationship between HIMSS and CCHIT
• Vendors who are involved at CCHIT are limited in what seats that can hold and what votes they can make
• CCHIT takes great pains to ensure that it is not biased by vendor ties.
• There is a strict conflict of interest policy in place

Mark is right to point these out, but this misses the heart of the criticisms coming from FOSS and other places.

The problem is not that there ’sneaky’ influences from HIMSS and Vendors, but rather a simple self-selection bias.

CCHIT is and always has been a monolithic check-list for a Proprietary, Rigid, Overweight, Bloated, Loaded, Expensive, and Massive  (or PROBLEM for short) EHR products that allowed out-patient doctors to effectively track and monitor the healthcare of their patients. Most of the ‘founding fathers’ of CCHIT were either vendors with a PROBLEM EHRs or EHR users who had already bought in to the PROBLEM EHR model.

The CCHIT process -is- open to all, it -is- democratic and it does seek to balance the interests of vendor and non-vendor participants. Everything Mark is claiming is right on and it does not matter at all. The participants in CCHIT have all bought into the PROBLEM model. Those of us who have always thought differently than CCHIT have stayed away because it was obvious from the get-go that the certification model put forward by CCHIT was incompatible with our goals.

Right now, CCHIT is taking it from all sides because there are so many people who disagree with some aspect of the PROBLEM model. Practice Fusion wants to see really cheap EHR services like the one that they offer be certified. The ‘Clinical Groupware‘ people want to see the certification of a suite of technologies that may or may not add up to a traditional EHR. The EMR-lite people want to see faster and lighter tools. The PHR people and consumer advocates want EHR systems that empower the patient instead of the provider. The Health 2.0 people want to see completely different models of finance and care become possible. Of course, the FOSS people (like me) want FOSS EHRs to get equal footing.

In defense of CCHIT, Mark and the other members of CCHIT that I have met have bent over backwards to try and see things from the FOSS perspective. They have truly listened and they are starting to understand how different our community really is. I would encourage the members of the other communities to consider working with CCHIT before discounting them. CCHIT needs to be given the opportunity to re-invent itself before it is discounted. The recent press release from CCHIT indicates that it will be establishing town hall meetings for the FOSS community. I am not confident that this will work, but it is an indication that CCHIT is willing to try and see things from a different vantage point.

However, it may be difficult for CCHIT to reinvent itself. Realistically, the PROBLEM EHR vendors and users do not want to see CCHIT supporting very different models then their own. If CCHIT appeases the crazies like me too much, it stands to loose its ‘base’. This is why I believe it is critical that ONC leave the door open to sources of certification other than CCHIT. Doing so keeps the pressure on CCHIT to broaden its certification systems to include very different philophies of Health IT. Without that extra pressure, there is no way for CCHIT to act in a way that is not in the direct interests of its current PROBLEM membership.

-FT

(update 6-03-09 Dr. Kibbe pointed out to me that the proper term was ‘clinical groupware’ and not health groupware. He also pointed me to an excellent post by Adam Bosworth defending exactly that perspective, so I linked it in. Also correct some spelling errors)