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Contributing Writer · Jun 24, 2010

Comparing HHS Certification to CCHIT

The question of Certification of Electronic Health Records (EHRs) has caused confusion among many physicians, clinics and hospitals. Under the American Recovery and Reinvestment Act of 2009 (ARRA), a new approach to certification came into play, which replaced the legacy method.

The traditional way that EHRs became certified was through CCHIT, which was the sole designated certifying source up until now. CCHIT was spawned from an EHR vendor trade organization (HIMSS), and created its own criteria for designating what an EHR “should” have in order to be certified. Given that the kinds of EHR vendors that dominate HIMSS are legacy “big iron” client/server systems – very expensive, very all-inclusive, very insular, and oriented to the large hospitals and medical groups that could afford such things – the certification criteria have leaned in that direction. Sort of a “you must look like me” approach to certification.

Under ARRA, the Office of the National Coordinator for Health IT (ONC) took a fresh look, and started from a definition of national health priorities (which was the result of a National Quality Forum report released in 2008 entitled “National Priorities and Goals”). From this overview, Meaningful Use criteria were developed, which defined what a physician must do in order to qualify for ARRA bonuses to be paid out beginning in 2011. Driven by these Meaningful Use criteria, new HHS Certification criteria have been proposed, and the details are being specified by the National Institute of Standards and Technology (NIST).

Given this new environment, CCHIT has responded by offering “preliminary” HHS certification, as a separate channel from its legacy certification. Even though CCHIT certification is not sufficient to access ARRA Meaningful Use money (only HHS Certification is), CCHIT has continued to make a case for its legacy program. To quote the CCHIT web site, “The Preliminary ARRA IFR Stage 1 program is simpler and more flexible, although it does not provide as much buyer assurance as the CCHIT Certified 2011 program.” This position certainly adds to a muddying of the waters, and confuses physicians and hospitals when it comes to adopting EHRs – the result is that potential EHR adopters may hold back and let matters become clearer.

To help shed light on the differences between what CCHIT claims is “important” in its legacy certification program and the new HHS Certification criteria, a side-by-side comparison is a useful exercise.

The CCHIT Certified 2011 Ambulatory EHR Criteria contains 286 items, grouped into a variety of categories. Compared to the HHS criteria, the CCHIT criteria are much more granular, and focus in much more detail exactly how records should be organized in an EHR. Many of these items are good ideas, and are not specifically tested by the HHS criteria (the NIST criteria set contains 30 items).

Many entire domains of CCHIT criteria are specific to locally-installed client server systems and the networks they must run upon – numerous documentation items, data backup items, installation and technical support for local deployment and product upgrades, and security specifications for nodes in a network. The assumption is that the EHR “universe” is a local network, which must be isolated from the “outside world” for the purpose of security. None of these specifications are relevant to web-based EHRs, which do not use local networks, which build security and privacy into their products in order to function properly on the Internet, and which do not need “local installation and support,” data backup, or upgrade worries. Of course, assurance of business continuity, data safety and security, and customer support are all important for web-based EHRs (just like they are for everyone) – but the CCHIT specifications do not address the needs of EHRs that are natively web-based.

Are there elements of the simpler HHS Certification that are not included in CCHIT’s exhaustive criteria-set? Yes – this is important to recognize.

The areas of HHS Certification that are not addressed by CCHIT certification are mainly around interoperability: (1) reporting PRQI measures electronically, (2) submission to and retrieval from Immunization Registries, (2) public health surveillance e-reporting, and (4) Computerized Physician Order Entry (CPOE) capture.

The vision of the ONC is to build an interoperable national health IT infrastructure, and much of the emphasis there is around interoperability (as opposed to the traditional all-encompassing enterprise legacy approach that has driven CCHIT). Taking CPOE as an example, the Stage 1 HHS Certification is simply to capture physician orders – in an ambulatory setting, there are 4 such orders to be captured: (1) medications/prescriptions, (2) laboratory test orders, (3)
imaging/x-ray ordering, and (4) referrals to outside providers. Stage 2 HHS Certification asks that these CPOE items actually connect with outside systems, and Stage 3 HHS Certification is expected to demonstrate outcomes (bending the curve). None of this is addressed by CCHIT certification.

A good way to look at all of this is as follows: CCHIT has had a legacy certification approach, which mainly looks at the details of how an EHR is put together, and how it functions in a closed, local network environment. The relevance of this going-forward is questionable – both HHS Certification, as well as the emergence of web-based EHR technologies, outstrip the vision of the traditional CCHIT approach.

HHS Certification, admittedly simpler (30 criteria vs. 286), is what counts when it comes to ARRA Meaningful Use incentive payments. It also includes kinds of functions that had not been addressed previously – mainly, interoperability with other outside systems.

Hospitals, physician groups, and organizations functioning as Regional Extension Centers should recognize this – it is HHS Certification (not CCHIT certification) that drives what should be included in an EHR system. The vision of the ONC to create an affordable, interoperable, and ubiquitous national health IT infrastructure is based on HHS Certification, and this is the approach that should be supported.

Robert Rowley, MD
Practice Fusion EMR