EHR Certification is Harmful to the Future of EHR

July 11, 2011

Certification is good for large, legacy companies. It anoints what they have already done thus minimizing the need to innovate in the future. It is in their interest to flex whatever political muscle they have to insure that certification is required.

Some EHRs are really terrible; others have notable strengths. The balance of strengths and weakness bears no direct relationship to the size of the company that produces the product. While smaller vendors often have trouble securing a large market share, many have been able to attract a group of physician customers who have found the products to be useful. These products frequently offer novel features that meet specific customer needs that are not addressed by the "big boys." This is another way of saying that much of the innovation that has occurred in EHR has originated with smaller companies. New, small companies do not have reams of legacy code that require maintenance and which might break if subjected to tinkering. Small companies also have much more incentive to be attentive to their customers' real requirements and modify their products accordingly.

Certification is good for large, legacy companies. It anoints what they have already done thus minimizing the need to innovate in the future. It is in their interest to flex whatever political muscle they have to insure that certification is required. It is also to their advantage if it is expensive, time-consuming, and bureaucratic; things which present obstacles to their small, upstart competitors.

Conversely, certification is bad for new, small companies. It requires that any EHR application offer a laundry list of features that may be of no importance to their target market. Features take time and money to develop. The certification process requires more time and money (~6 figures) to complete successfully. This has had the effect of driving small companies out of existence while ensuring that there will be fewer startups in the future. Without new competition, the pressure to innovate is off of the legacy firms. They offer what the certification criteria say that physicians need - the government said so. There is no need and not much incentive to take on the risk and expense of being innovative.

Certification is also bad for practices that have successfully implemented an EHR purchased from a vendor that could not afford to certify. The developers of those products will be forced out of business by the lack of new customers and the lack of on-going revenue from their former customers, who will abandon them in order to secure incentive payments.

Consider the reasoning behind the push for EHR: a good computer system will make medical care safer and more efficient, thereby driving down the cost. Consider a scenario in which a practice is using an uncertified system that has been, and is, contributing to their profitability by making them more efficient. Replacing that system with a new, certified system could make them less efficient. Since the incentive is a one-time payment, but the efficiency or its lack is the "gift that keeps on giving," in the long run, a new EHR could make the practice permanently less profitable. A switch also jeopardizes existing computerized records. Making a switch often requires abandoning the data in the old system. Without the historical data, it will take a long time before the new system will accumulate enough data to enable it to deliver its benefits, even if it is certified and capable of supporting efficient practice.

Is this really what Congress and CMS intended? Listening to an interview with Don Berwick of CMS on Medscape recently, I'm not sure that it is. Dr. Berwick seems very results-oriented. CMS has a number of initiatives through their Innovation Center that are focused on results, not the means by which the results are obtained. Therefore, it seems inexplicable that in the area of EHR, the policy is to focus on the means and only secondarily, to consider the results.

If a practice can accomplish the meaningful use goals by using an uncertified EHR, what else would be gained if it were certified? Knowing how hard it can be to select the right system, perhaps the chosen certified EHR is a poor fit with the practice style and workflow in an office and actually interferes with meeting the meaningful use criteria. What has been accomplished by coercing that practice into buying a certified product? If they spend the money and effort but fail to qualify for the incentive, aren't they worse off than if they had done nothing?

Many practices run the risk of an unexpectedly poor outcome regardless of what decision they make. Furthermore, the benefits that Congress hopes will result from their policies may take longer or may be made unattainable because of those very policies. At the very least, it is almost inevitable that the rate of EHR innovation will be slower in the future with the certification requirements than it would be without them.

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