08 - Installation and Maintenance of Health IT Systems - Unit 2 - System Selection - Software and Certification

This material Comp8_Unit2 was developed by Duke University, funded by the Department of Health and Human Services,
Office of the National Coordinator for Health Information Technology under Award Number IU24OC000024.
Installation and Maintenance of
Health IT Systems
System Selection
Software and Certification
System Selection
Learning Objectives
2
Health IT Workforce Curriculum
Version 3.0/Spring 2012
Installation and Maintenance of Health IT Systems
System Selection Software and Certification
1. Compare and contrast COTS
(Commercial Off-The-Shelf) and In-House
/homegrown systems and describe their
relative advantages and disadvantages
2. Verify system compliance with ONC-
ATCB certification
3. Identify purpose and categories of ARRA
Meaningful Use criteria
3
Off-the-Shelf Software
Commercial Off-the-Shelf (COTS)
Modifiable Off-the-Shelf (MOTS)
200+ companies claim to make an EHR
(Electronic Health Record)
May include freeware with commercial
support

4
Advantages of COTS
Lower development costs
Wider test market to find bugs and
limitations
Vendor training and product support, bug
fixes
Easier learning curve
Eliminate development time
5
Disadvantages of COTS
Unalterable source code
Compatibility issues
Uncertain upgrade schedules
Business practices may have to be
modified, and workflow often has to be
adapted to the particular product design.

(Rice, 2009)
6
In-House / Homegrown
Locally-installed and managed EHR
implementation
Only available to institutions with existing
IT infrastructure and investment
Developed by
extending existing In-House systems, or
adapting open-source or other publically
available software for institution needs

7
Advantages of In-House
Developed wholly by the operating
institution
Design is specifically tailored to meet
institutional objectives
Can mesh comfortably with existing
workflow processes
8
Disadvantages of In-House
Higher development costs, initial and
throughout product lifecycle
Dependent on expertise of in-house
development staff
Lack of vendor support bug fixes,
upgrades
Training must be developed in-house.
Longer development time
9
EHR Certification
Office of the National Coordinator for Health Information Technology (ONC)
provides for a certification program for EHR Technology
Temporary Certification Program in effect June 2010
Permanent Certification Program in January 2011, replacing temporary program in
2012
American National Standards Institute (ANSI) is the ONC-Approved
Accreditor (AA) for the Permanent Certification Program ANSI will certify
the ATCBs
Only 6 ATCBs as of Dec. 2011 (http://healthIT.hhs.gov/ATCBs)
ATCBs are the Authorized Testing and Certification Bodies that grant
certification to the products and vendors of Complete EHRs and EHR
Modules.
Current list is available at http://onc-chpl.force.com/ehrcert
Certification is a prerequisite for participation in the Medicare and Medicaid
incentive programs, which provide payment to doctors, clinics, and hospitals
that demonstrate meaningful use of certified EHR technology

(ONC, 2011; CMS 2011)
10
Standards and Certifications
Criteria Final Rule
Final Rule on an initial set of standards,
implementation specifications, and
certification criteria adopted July 13, 2010
Interoperability, to work with systems sharing
information
Functionality, to perform a set of well-defined
functions
Security, to store and transmit confidentially and
reliably
Utility, to support meaningful use of HIT data
(SCCFR)
11
Why Certification?
Reduce risks to physicians in EHR
investment
Facilitate interoperability of EHR systems
Enhance availability of EHR adoption
through stimulus incentives
Ensure that EHR systems and networks
are secure and protect privacy

(Pizzi, 2007)
12
Why Certification? (contd)
Allow evaluation time to be used more
efficiently
Narrow the initial field of vendors
Assure basic functionality and
interoperability, allowing you to
focus evaluation more on special or
unusual needs of your institution
13
What are ARRA and
Meaningful Use?
ARRA (American Recovery and Reinvestment Act,
a.k.a. stimulus bill)
Passed by Congress February 2009
Over $22 billion allocated to modernize health IT
system.
HITECH (Health Information Technology for
Economic and Clinical Health) Act: initially rewards
institutions for meaningful use of EHRs, then in
2015 imposes penalties.

(Hitechanswers)
(Recovery.org, 2009)
(cms.gov, 2011)
14
Meaningful Use Criteria:
Stage 1
According to Centers for Medicare & Medicaid
Services (CMS), the priorities for hospitals &
providers are to:
1. Improve quality, safety, and efficiency, and reduce
health disparities
2. Engage patients and families in their health care
3. Improve care coordination
4. Improve population and public health
5. Ensure adequate privacy and security protections
for personal health information

(CMS, 2011)
15
Stage 1 (contd)
1. Improve quality, safety, and efficiency, and reduce
health disparities
Computerized Provider Order Entry (CPOE, directly
entered by authorizing provider) for 10+% of all
orders
Drug-drug, drug-allergy, drug-formulary checks
Up-to-date problem list of current and active
diagnoses, based on ICD-9 or SNOMED
vocabularies
Active medication list
Active medication allergy list

(CMS, 2011)
16
Stage 1 (contd)
1. Improve quality, safety, and efficiency, and
reduce health disparities (cont'd)
Demographics
Preferred language, insurance type, gender, race,
ethnicity, date of birth, date and cause of death
Vital signs
Changes in height, weight, blood pressure; calculate
and display Body Mass Index (BMI); plot and display
growth charts, including BMI, for children 2-20 years

(CMS, 2011)
17
Stage 1 (contd)
1. Improve quality, safety, and efficiency, and
reduce health disparities (cont'd)
Smoking status (13+ years old)
Laboratory test results as structured data
Lists of patients by specific conditions
Report quality measures to CMS or states
Five clinical decision support rules, including for
diagnostic test ordering, along with ability to track
compliance
Submit claims electronically, public and private

(CMS, 2011)
18
Stage 1 (contd)
2. Engage patients and families in their
health care
Provide patients with electronic copy of health
information upon request
Diagnostic test results, problem list, medication lists,
allergies, discharge summary, procedures
Discharge instructions at the time of discharge

(CMS, 2011)
19
Stage 1 (contd)
3. Improve care coordination
Electronically exchange key clinical
information
Medication reconciliation at relevant
encounters and each transition of care
Summary of care record for each transition of
care and referral

(CMS, 2011)
20
Stage 1 (contd)
4. Improve population and public health
Capability to:
Submit data to immunization registries
Submit data on reportable lab results (as required
by state or local law) to public health agencies
Provide electronic syndromic surveillance data to
public health agencies
Actual data submissions under certain
circumstances

(CMS, 2011)
21
Stage 1 (contd)
5. Ensure adequate privacy and security
protections for personal health information
Protect electronic health information created
or maintained by the certified EHR technology
through the implementation of appropriate
technical capabilities.

(CMS, 2011)
22
Next Stages
Projected timeline of implementation
Stage 2: 2013
Stage 3: 2015
Requirements
Not yet officially defined
Expected to require taking stage 1 functions
even further; e.g., increasing e-prescribing
from 40% to 50% (stage 2) and then to 80%
(stage 3)
(Federal Register, 2011)
23
Typical EHR Costs to Consider
Start up costs
Initial hardware and network upgrades
Initial software and licensing
Initial interfaces
Maintenance costs
Annual software licensing, upgrades, support
Annual interface upgrades and support
24
Typical EHR Costs to Consider
(cont'd)
Training costs
Administrators
Users
Productivity costs
Lost during transition
Consultant fees
System Selection
Summary
COTS advantages and disadvantages
weighed against in-house advantages and
disadvantages
Costs involved in startup and maintenance of
the system should be addressed
Certified systems and modules are preferred
Meaningful use priorities should be
addressed

25
System Selection Software
and Certification
References
References

About ARRA. Retrieved from HITECH Answers website: http://www.hitechanswers.net/about/about-arra/
ARRA Meaningful Use Snapshot. (n.d.). Retrieved from Medical Information Technology, Inc. website:
http://www.meditech.com/interoperability/pages/ARRA_snapshot_final_0311.pdf
Certified Health IT Product List. Retrieved from Office of the National Coordinator for Health Information
Technology, US Department of Health & Human Services website: http://onc-chpl.force.com/ehrcert
Electronic Medical Record [cited 2010 June 20]. Retrieved from:
http://en.wikipedia.org/wiki/Meaningful_Use#Meaningful_Use
EHR Incentive Programs Overview. (n.d.). Retrieved from Centers for Medicare & Medicaid Services website:
https://www.cms.gov/EHRIncentivePrograms/
Medicare and Medicaid Programs; Electronic Health Record Incentive Program (2010, July). Federal Register.
[Internet]. Retrieved from http://www.federalregister.gov/articles/2010/07/28/2010-17207/medicare-and-medicaid-
programs-electronic-health-record-incentive-program .
Fornes, D. (2008, February 6). Should CCHIT Influence Your EHR Selection? [Web log post]. Retrieved from
Software Advice - The Medical Blog: http://blog.softwareadvice.com/articles/medical/should-cchit-influence-your-
ehr-selection
Gates, M. (2009, Winter). All Systems Go? How to Select an EHR That Meets Your Needs. Correct Care,
Retrieved from http://www.ncchc.org/pubs/CC/selecting_ehr.html

26
27
System Selection
References
References

Goals for EHR System. Retrieved June 20, 2010, from Health Technology Review website:
http://www.healthtechnologyreview.com/viewarticle.php?aid=113
HITECH Act Enforcement Interim Final Rule. (n.d.). Retrieved from U.S. Department of Health & Human Services
website: http://www.hhs.gov/ocr/privacy/hipaa/administrative/enforcementrule/hitechenforcementifr.html
McKinney, D. (2001, August). Impact of Commercial Off-The-Shelf (COTS) Software and Technology on Systems
Engineering. Retrieved from Presentation to INCOSE Chapters website:
http://www.incose.org/northstar/2001Slides/McKinney%20Charts.pdf
Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Final Rule, 75 Fed. Reg. 44314
(2010) 42 CFR Parts 412, 413, 422, and 495 http://edocket.access.gpo.gov/2010/pdf/2010-17207.pdf
ONC-Authorized Testing and Certification Bodies. Retrieved from Office of the National Coordinator for Health
Information Technology, US Department of Health & Human Services website: http://healthIT.hhs.gov/ATCBs
Pizzi, R. (2007, October 30). EHR adoption an "ugly process," but CCHIT can improve appeal. Retrieved from
Healthcare IT News website: : http://www.healthcareitnews.com/news/ehr-adoption-ugly-process-cchit-can-
improve-appeal
Rice, R. (2009). Testing COTS-Based Applications . Retrieved June 21, 2010, from
http://www.riceconsulting.com/articles/testing-COTS-based-applications.htm

28
System Selection
References
References

Standards & Certification. Retrieved from Office of the National Coordinator for Health Information Technology, US
Department of Health & Human Services website:
http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__standards_and_certification/1153
Standards & Certification Criteria Final Rule. Retrieved from Office of the National Coordinator for Health Information
Technology, US Department of Health & Human Services website:
http://healthit.hhs.gov/portal/server.pt/community/healthit_hhs_gov__standards_ifr/1195

Images
Slide 13: ARRA recovery.gov logo http://www.recovery.gov/News/mediakit/Picture%20Library/circle_recovery_logo.jpg
Slide 13: Center for Medicare and Medicaid Services EHR Incentive Programs logo
http://www.cms.gov/EHRIncentivePrograms/Downloads/EHRIncentiveLogoweb.JPG

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This material Comp8_Unit2 was developed by Duke University, funded by the Department of Health and Human Services,

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