Digitized Medicine

Dangerous Precedent Set To Financially Penalize Doctors Who Fail to Influence Patient Behavior

I strongly oppose use of quality measures that incentivize or penalize physicians based on their ability to influence patient actions when those actions are beyond reasonable control of physicians or if there is no evidence linking such actions to improvements in patient outcomes.    That is why I believe there is a dangerous precedent being set in the Stage 2 electronic health record (EHR) incentive payment rule which will penalize physicians if they fail to influence patient behavior in a manner desired by the Centers for Medicare &  Medicaid Services (CMS).    

Two of the 17 Stage 2 core objectives hold physicians accountable for ensuring that their patients use technology at home.   One measure requires at least 5% of unique patients seen during the reporting period to send a secure message to the physician's practice using the electronic messaging function of the EHR.   A second measure requires at least 5% of unique patients seen during the reporting period electronically view, download or transmit their health information.   

In order to qualify for Medicare and/or Medicaid EHR incentive payments and avoid financial penalties, physicians must meet all 17 core measures as well as three from a menu of six additional measures.    Physicians must also report on nine of a total of 64 specific clinical quality measures.  Physicians who fail to do so by 2015 will not only fail to receive annual EHR incentive payments, but also be penalized by CMS through annual payment adjustments. 

In the final rule for the Stage 2 EHR Incentive Program CMS responded to public comments on these two new core objectives. CMS argued that physicians are in a unique position to strongly influence the use of technologies by patients "to improve their own care."    They did acknowledge a potential barrier of limited broadband internet access that could impact some physician practices and patients.   So in the final rule CMS lowered the threshold from 10% to 5% and added an exclusion for practices that are impacted by limited broadband access.   CMS summarized their response with, "We believe that this lower threshold, combined with the broadband exclusion detailed in the response, will allow all EPs (eligible physicians) to meet the measure of this objective."

I can agree with CMS that physicians should leverage the influence we have on patient behaviors as part of the care we provide.   We certainly are in a unique position to help patients become more engaged in and compliant with their healthcare.   I even agree with CMS that the lower thresholds should not be difficult to meet and that it is important for physicians to offer these technologies for patients to use.    

My key point of contention with CMS is with the presumption that use of these specific technologies at home allows patients to "improve their own care".    If use of these technologies were objectively linked to improved patient outcomes, I could understand the value in financially incentivizing physicians to move patients in that direction.   Without such evidence the government's relationship with physicians would be better served through a more tactful approach to promote the use of promising technologies by patients without the strong-armed threat of financial penalties on doctors. 

CMS misses the point on this one.    Precedent should not be set to penalize physicians based on measures of their ability to engineer desired patient behaviors when those behaviors are not objectively linked to improved patient outcomes.   I am not saying that we should not offer these technologies to our patients.    I am saying that we should promote their use and then study how that use impacts the quality of care

 

 

Keep the data collection cart behind the trailblazing horse

In today's Health IT News there is an article expressing dissappointment with the recently released proposed rules for Stage 2 of the Electronic Health Record (EHR) Incentive Program.   Some alarming viewpoints are evident in this article regarding the collection of data for use by the federal government to improve public health .

The proposed rule for Meaningful Use Stage 2 on page 13702-13703 specifically states that the purpose of Stage 2 Meaningful use is to "“encourage the use of health IT for continuous quality improvement at the point of care and the exchange of information in the most structured format possible”.    No where in the rule does it state that the primary purpose of Stage 2 Meaningful Use is to collect data for use by the federal government as is suggested by concerns expressed in this article.   Let's keep the data collection cart behind the trailblazing horse so that it does not aimlessly roll down the steepest part of the hill instead of steering toward most beneficial path.   Stage 2 objectives draw a sensible roadmap to the next planned destination where we can finally begin realizing the maximum potential value of health IT and EHRs.   We currently have the horse trotting around potholes toward the widespread adoption and successful use of EHRs, the development of robust HIE networks, the maturation of EHR product functionalities and an improved understanding of safe EHR usage.   If we fail to align Stage 2 activities with Stage 2 goals by taking unplanned shortcuts to collect and use data in hopes of improving care now, I fear the cart will crash and cripple the momentum that Stage 1 has initiated.

Progress being made to splice information technology into the healthcare industry's genome in Texas

It's amazing-the progress being made to splice information technology into the health care industry's genome.   When I first dove into health IT a decade ago the use of electronic health records (EHRs) was dismal and healthcare stakeholders rarely sat at the same table with mutually beneficial, collaborative objectives in mind.   Even within the same healthcare organization it was not uncommon for individual department leaders to disrupt an integrated health IT effort in order to protect some of their department's self-interests.   Less than 5% of hospitals had implemented fully functional computerized provider order management (CPOM) systems; less than 1 in 5 physicians were using an ambulatory EHR; and less than 5% of those were fully functional EHRs.    Today the percentage of physicians and hospitals using robust EHRs is rising at a rate that was unthinkable back then.  

This progress parallels the launch of health IT initiatives established through the federal HITECH funds such as the EHR Incentive Program.   In the past two years these funds have been a catalyst here in Texas to engage diverse groups of healthcare stakeholders  to use health IT to improve quality of care.   As a result:  

• Increasing numbers of Texas physicians are using EHRs (approaching 50%)
• More and more hospitals are using CPOM
• Over a dozen of community-wide health information exchanges (HIEs) are up and running
• New health IT workforce training programs are established
• Four regional extension centers were formed covering all geographic areas of the state and are doing a phenomenal job assisting thousands of physicians with EHR selection, implementation and meaningful use
• Texas became the first state to have it’s HIE plan approved by ONC
• Texas was one of the first states to stand up the Medicaid EHR incentive program making our program a model for other states
• Texas was one of four to receive a SHARP grant
• And Texas leads the way with the number of physicians attesting to meaningful use; Texas physicians and hospitals have received over $270 Million in EHR incentives

This rate of progress is only possible when individuals with diverse backgrounds and from different healthcare stakeholder groups are able to collaborate.  In Texas these stakeholders have demonstrated an ability to park their self-interests in order to drive forward with a common vision to improve the quality and delivery of patient care in our communities.

Snapshot of EHRs Used in Texas to Achieve Meaningful Use Gives Glimpse of Regional EHR Market Consolidation

Over 400 electronic health record (EHR) vendor products are certified by the Office of the National Coordinator of Health IT (ONC), but only a handful of them are used by a majority of the physicians in Texas who have been awarded EHR incentive payments by the Centers for Medicare and Medicaid Services (CMS) according to an ONC database released last week.

Physicians who successfully meet CMS criteria that demonstrate their “meaningful use” of an ONC-certified EHR become eligible for incentive payments up to $44,000 over 5 years under the Medicare program or $21,500 over 6 years under the Medicaid program. The ONC database includes the records of 21,697 physicians who have received EHR incentive payments so far, de-identified by physician but including the physician’s EHR product name, the physician’s state and whether payment was received through the Medicare or Medicaid programs. There are 217 EHR vendors listed as having products that had been used successfully by at least one eligible physician.

In Texas 1,585 physicians have received EHR incentive payments according to the database. Although 75 different ambulatory EHRs were used by at least one physician, only six of them were used by more than 100 physicians. These six EHRs account for 69% of the EHRs used in Texas to achieve meaningful use.    They are listed here with the number and percent of physicians using each to achieve meaningful use:

• Epic 277 (17%)
• eClinicalWorks 249 (15%)
• e-MDs 177 (11%)
• Allscripts 170 (11%)
• Athenahealth 128 (8%)
• NextGen 114 (7%)

The following graph displays the 25 EHRs that at least 10 Texas physicians have used to achieve meaningful use payments (click to enlarge):

There are 50 other EHRs used by less than 10 physicians in Texas who have successfully attested for meaningful use incentive payments.   These are listed at the end of this blog.

Across the nation Epic is the early leader with over 25% of physicians using it to achieve meaningful use. The top five EHRs nationally–Epic, eClinicalWorks, Allscripts, athenahealth and Community Computer Services–are used by nearly 49% of the physicians.    The top 13 EHR vendors nationally are used by more than 75% (see list below).   There are variations in regions across the nation, though, as seen with the Texas data.

It is interesting to note in Texas that the first three of the top six EHRs used to achieve meaningful use–Epic, eClinicalWorks and e-MDs–are all private companies.   The other three are public companies–Allscripts, NextGen and athenahealth.  They all all generally have positive reputations and perennially receive a variety of “Best in KLAS” rankings.    Epic’s ambulatory EHR is used primarily by physicians affiliated with large health centers and is not currently a feasible option for many small practices in rural Texas.    Athenahealth is marketed as a web-based EHR, but the others can be web-based as well.   Although e-MDs is popular nationally, their market share in Texas benefits from their headquarters being located locally in Austin.    

In the past decade many speculated that CCHIT certification of EHRs, which is more comprehensive than the ONC-certification for meaningful use, would spur a consolidation of what is currently a disperse EHR market with hundreds of vendors supplying products.  Others felt that free market forces, with physicians in the center creating demand for EHRs that worked well, would eventually swing the pendulum toward consolidation.   It is still early, but the data set in the ONC database gives a provocative glimpse at the EHR market forces in play today.  There is clearly some consolidation around a small number of EHR products after the first year of the CMS EHR Incentive Program.    I suspect physician demand for EHRs that simplify their ability to receive incentive payments will continue to play a significant role in swinging the EHR market pendulum towards consolidation over the next decade. 

 

Additional data:

The top 13 EHRs used by physicians nationally for EHR incentive payments were:

#Providers         Vendor Name

6330                     Epic Systems Corporation

1847                    eClinicalWorks LLC

1502                    Allscripts

1158                    athenahealth, Inc

999                      Community Computer Service, Inc.

921                       GE Healthcare

899                      NextGen Healthcare

770                      e-MDs, Inc.

712                     Greenway Medical Technologies, Inc.

567                     Cerner Corporation

565                     Sage

397                     BioMedix Vascular Solutions

252                     AmazingCharts.com, Inc.

 

The following 50 vendors had less than ten physicians in Texas using them to achieve meaningful use incentive payments:

Meditab Software, Inc.

HealthFusion

Pulse Systems

Altos Solutions, Inc.

Integrated Health Care Solutions

MED3000, Inc

Waiting Room Solutions

BizMatics Inc

Compulink

Crystal Practice Management

digiChart, Inc.

NexTech Systems Inc.

American Medical Software

ICANotes, LLC

MicroFour, Inc.

Prime Clinical Systems, Inc.

ADP AdvancedMD

Altapoint Data Systems, LLC

Ingenix

Intivia, Inc.

MedPlus, A Quest Diagnostics Company

MTBC (Medical Transcription Billing Corporation)

Nuesoft Technologies, Inc.

Spring Medical Systems, Inc.

SuiteMed

UnisonCare Corporation

AllegianceMD Software, Inc.

Cerner Corporation

CodoniX

CureMD Corporation

Data Strategies, Inc.

DoctorsPartner, LLC.

DrChrono.com Inc.

DrFirst

EMRlogic Systems

Encite, Inc.

Exemplo Medical LLC

E-Z BIS, Inc.

gMed, Inc.

Health IT Services Group

Insight Software, LLC

Medical Office Online, Inc.

MedInformatix, Inc

MedLink International, Inc

Medrium Inc.

Midwest Software, LLC

MPN Software Systems, Inc.

Net Health Systems, Inc.

Sammy Systems

WellCentive

Bipartisan Health IT Support and ARRA Insulate EHR Incentive Funds From Budget Cuts

A physician colleague recently asked me why I am confident that CMS will not cut off EHR incentive funding in the future.   This question is important to him and other physicians who plan to qualify for up to $44,000 in CMS incentive payments by achieving the meaningful use of EHRs.   They fear that the dragging economy and political discord will result in budget reductions that will cut this and other important health IT funding programs.    What I see, though, is a decade-long track record of bipartisan support for health IT initiatives and a 2009 federal law that requires CMS to provide funding for the EHR incentives and other health IT programs.

In his 2004 State of the Union speech President Bush envisioned the adoption of EHRs for all Americans by 2014.   Since then bipartisan support at both the state and federal levels for health IT initiatives toward the achievement of that vision has held strong.   At the federal level CMS  not only established a new office in 2004 to support health IT, the Office of the National Coordinator of Health IT (ONC) but has also increased funds to support ONC initiatives which promote the adoption and use of EHRs.  CMS works collaboratively with ONC and has consistently shown an understanding that the broad adoption and effective use of EHRs are necessary to better manage spiraling healthcare costs.   CMS understands that the data captured by EHRs is superior to claims-based data when attempting to analyze quality and establish benchmarks.    Physicians have long complained that claims-based data is incomplete and does not fairly demonstrate the quality of care they provide.     EHRs must be broadly adopted in order to capture accurate and meaningful data that can then be used to improve quality or save costs.  

It is important to recognize that CMS is required to provide EHR incentives to physicians by law.   Specifically, the $800 billion American Recovery and Reinvestment Act (ARRA) of 2009, commonly refered to as the Stimulus Bill, allocates over $36 billion to health IT programs through the Health Information Technology for Economic and Clinical Health (HITECH) Act.   This funding includes an estimated $34 billion for the Medicare and Medicaid EHR Incentive Program and over $300 million to support state-wide health information exchange efforts.

In order to cut funding for EHR incentives, this means that bipartisan support would have to be garnered in the House and Senate to rescind ARRA or part of ARRA.   The intent of ARRA  initiatives is to stimulate economic activity and produce jobs.   In the current economic environment it would seem very risky, perhaps even foolish, for a politician to drum up support for new legislation that eliminates economic stimulus activity, especially if that activity is already producing jobs.

So, is the EHR Incentive Program stimulating the economy and producing good jobs?   I am not an economic expert, but from what I see around me the answer is clearly, "yes".    I see job openings in the local paper for healthcare system IT analysts and other staff, I speak with IT consultants most of whom are actively seeking personnel, I hear about physician offices investing into the economy $10,000-$70,000/doctor to implement EHRs or upgrade other office technologies, I read about physicians receiving $44,000 federal incentive payments and about hospitals receiving larger amounts, some of which is surely returned into local economies.  The graph below is a composite view of the 3-year stock performance of the health IT sector since 2009.   EHR vendors and other health IT companies appear to be thriving well since ARRA was passed despite the depressed economy.

I suspect that several years from now when experts analyze the impact of the $800 billion stimulus package, the puny $36 billion provided to health IT initiatives through the HITECH portion of ARRA will go down as perhaps the most bang for the buck in terms of stimulating the economy.  

The EHR incentive funds appeared to be well insultated from budget cuts for these same reasons. 

Texas Medical Association video provides in-depth look at meaningful use, how RECs can help physicians

This video does a good job of describing Meaningful Use, the electronic health record (EHR) incentive program and how the four regional extension centers (RECs) in Texas leverage federal grants to subsidize services for physicians that help them select/implement or upgrade an EHR, and then use their EHR to improve quality of care and meet the Meaningful Use requirements.  

The four RECs in Texas currently charge primary care physicians only $300 for consulting services valued at $5,000.  These services include:

o    Select and implement a certified EHR (or upgrade your current EHR to a certified version)

o    Optimize your practice workflow,

o    Achieve meaningful use,

o    Qualify for EHR incentives, and

o    Obtain CME credit hours      

 cook children's

Twitter Chats and Physicians (#eRx630)

Today I (as @drmattmurray) and @TexMed moderated our first Twitter Chat that focused on the topic of e-prescribing. To participate in a Twitter Chat a physician must have a Twitter account and must know the date, time and Twitter hashtag for the Twitter Chat.  In our case the hashtag-- #eRx630--refers to e-prescribing and the date, June 30th, by which time physicians must meet the CMS requirements regarding the use e-prescribing. Physicians who fail to use a qualified e-prescribing system or certified EHR to enter at least 10 e-prescriptions during eligible Medicare encounters will incur a 1% penalty on 2012 Medicare claims.    On the other hand, those who meet this requirement are eligible for a 1% bonus. 

Despite the high importance of this subject matter, there were not any other physicians participating on this particular Twitter Chat.   At least none that we heard from.   It was lonely.  

However, we considered this to be an experiment and a chance to experience what it is like to actually moderate a Twitter Chat.    Without a lot of participating "chit-chat", it was difficult to coordinate questions and answers with my friends @TexMed and @TexMedHIT.     We basically asked each other questions or even asked ourselves for our own answers.  I think we did get out some excellent information, but this would have been more valuable with some active back-and-forth dialogue.   Again, though, the purpose of this venture was to dip our toes in the water to see how this type of format could be used in the future. 

Twitter Chat among physicians will certainly have challenges, but I think it will find it's place as a useful mode of communication for specific purposes and in certain situations.  The format will need to be refined, and this means we will have to try it (like today!), experiment with it, refine it and keep doing that PDSA thing to it (Plan-Do-Study-Act).   Eventually it will find a place where it serves as an effective way to communicate some things.     I already have found Twitter useful at large medical conferences that use a hashtag to communicate real-time information.    It is a matter of finding the right niches. 

One of the useful aspects of a Twitter Chat is that a transcript can be created of the entire conversation.  This means that you don't have to be "online" and engaged in the Twitter stream for the entire duration of the chat.   Since most physicians are hard pressed to find an un-interrupted hour, they would find it very helpful to be able to access and peruse the transcript at their leisure.

Here is a transcript of today's Twitter Chat #eRx630:

 
 
 
 
 
 
 
 
 

Why should primary care physicians enroll for Regional Extension Center services?

Why should primary care physicians sign up for REC services?   What are the unique selling points and assistance they will receive as compared to other consultant organizations?  

These are excellent questions I am hearing from physicians in Texas regarding the four RECs that cover our entire state.  The RECs are subsidized by the federal government through the Health Information Technology for Economic and Clinical Health (HITECH) Act which appropriated $640 million in REC grant funds to create 62 RECs across the nation, including the four in Texas. 

Primary care physicians in Texas should use REC services because they will receive a steep discount for high quality services that are provided through a trustworthy, physician-centric organization that was specifically created to meet the technological needs of physicians in their region.

In Texas the four RECs have collaborated to develop a shared business plan that leverages the federal subsidies to provide onsite technical consulting for a token fee of $300.    For this $300 enrollment fee Texas physicians receive over $5,000 in consulting services which include:

• EHR implementation and project management;
• HIT education and training; 
• Vendor selection and financial consultation; 
• Practice and workflow redesign; 
• Privacy and security compliance education; 
• Meaningful use analysis, tracking, and monitoring; 
• Assistance in meeting meaningful use requirements for CMS incentives; 
• Collaboration with state and national health information exchange (HIE); 
• Ongoing technical assistance; and 
• Opportunities for CME credit hours

In addition to this steeply discounted enrollment fee, the Texas Medical Association (TMA) works closely with the RECs to help ensure that the RECs are physician-centric and focused on meeting physician needs.    Physicians hold 50% of the seats on each REC's governing board as a result of the TMA’s early efforts.

Another unique selling point is that the REC technical consultants are specifically focused on, and experienced with, the small physician practice.    Other IT consultants naturally give priority to large practices or healthcare systems where they get large amounts of money from a small number of contracts.    The REC consultants, on the other hand, only get a small amount of money per contract, but they get a large number of them.    This business strategy allows them to become more experienced with and more focused on the small practice.    The REC administrative staffs enable this strategy by facilitating the enrollment of a large number of physicians and by using the REC federal grant funds to offer physicians the steep discount.

The four RECs in Texas are:

• Gulf Coast Regional Extension Center (GCREC)
• CentrEast Regional Extension Center (CEREC)
• North Texas Regional Extension Center (NTREC)
• Texas Tech University Health Science Center

North Texas Regional Extension Center's Successful Start and Current Activities

Today, while wearing my hat as the Board Chairman of the North Texas Regional Extension Center, I am writing a message primarily to my colleagues who practice medicine across North Texas.   I am sharing this message through my blog, however,  because others may be interested to see and hear what is happening at the grassroots level of local and regional health IT initiatives:

 

  
 February 2, 2011

To my physician colleagues across North Texas,

On behalf of the volunteer physician board members of the North Texas Regional Extension Center (NTREC), I am writing to inform you that registration for the federal electronic health record (EHR) incentive program has begun and that the money is already flowing.   In January, for example, two Oklahoma physicians at the Gastorf Family Clinic of Durant, OK, received $21,250 each for having implemented a certified EHR.   If you are considering making the jump to an EHR, or if you already use one, you may become eligible for EHR incentives up to $44,000 under Medicare or $63,750 under Medicaid by meeting “meaningful use” requirements.

NTREC receives federal grant funds for providing on-site technical consulting to enrolled physicians who are selecting, implementing or using an EHR.   This federal subsidy allows NTREC to charge primary care physicians only $300 for consulting services valued at $5,000.  

NTREC is focused on helping you:

• Select and implement a certified EHR (or upgrade your current EHR to a certified version),
• Optimize your practice workflow,
• Achieve meaningful use,
• Qualify for EHR incentives, and
• Obtain CME credit hours along the way

I am happy to report that NTREC services were successfully launched four months ago.   Since then, 289 physicians have enrolled for services and another 370 physicians have enrollment contracts in progress.   Our goal is to provide services to more than 1,500 physicians in North Texas by the end of 2011.   Our operational plans will enable us to scale physician services to even higher levels if needed to meet physician demand.  

The federal EHR incentive program and these discounted NTREC consulting services are unprecedented and genuine.   Please call NTREC to enroll and set an appointment for on-site consulting at (469) 648-5140 or by visiting  www.ntrec.org.   The NTREC’s dedicated team of experts will be considerate of your valuable time and show you how they can help you identify and meet your unique needs.

If you have questions, please don’t hesitate to contact me.

 

Sincerely,

 Matt Murray, M.D.

Brown Lupton Health Center

Texas Christian University

 

cook children 

For Meaningful Use Payment: Goin' to the CHPL, Gonna Get a "CMS EHR ID"

Use of certified electronic health record (EHR) technology is a core requirement for physicians and hospitals to become “meaningful users” and to be eligible for payments under the Medicare or Medicaid EHR incentive programs.    Operationally, CMS requires providers who apply for these payments to submit the "CMS EHR ID" that their certified EHR technology is assigned.   Physicians and hospitals will benefit from an awareness of several issues revolving around EHR certification and on this CMS EHR ID, especially when "goin' to the CHPL" as noted below.

Awareness Issue #1:  The Office of the National Coordinator for Health Information Technology (ONC) in 2010 established a temporary certification program for EHR products.    A permanent certification program, which builds upon the current temporary program, is expected to be ready to launch by the end of 2011.   This program uses ONC-Authorized Testing and Certification Bodies to test and certify EHR products.   The list of certified EHRs is updated as new products are certified and posted on the Certified HIT Product List (CHPL) website.    CHPL is maintained by ONC and is the sole, designated authoritative list of currently certified EHR products.  

Awareness Issue #2:    ONC certification is different from that provided by the Certification Commission for Health Information Technology (CCHIT).    CCHIT certification is based on more comprehensive criteria.    CCHIT certification continues to be an important resource for those who are in the process of selecting an EMR because of this more comprehensive testing.    ONC certification testing, on the other hand, is specifically based on the CMS Meaningful Use criteria. 

Awareness Issue #3:   EHR products are tested and certified by ONC as either a Complete EHR or a Modular EHR.   A Complete EHR product is defined as an EHR product that meets all of the certification criteria for meaningful use.  A Modular EHR product is defined as an EHR product that meets at least one but not all meaningful use criteria.

Awareness Issue #4:   When a physician or hospital apply for their incentive payment they are asked to submit to CMS the "CMS EHR ID" that is assigned to their EHR product(s).  The CHPL website is the only place where this ID number can be found.  

Awareness Issue #5:    When looking for this CMS EHR ID number, it is helpful to know that this is not the same number ONC provides the EHR vendors when they are certified.    This is because some providers may decide to use a modular approach and combine Modular EHR products from different vendors in order to achieve meaningful use (i.e. a basic EMR without e-prescribing from one vendor and an e-prescribing module from another).  

Awareness Issue #5:   As the website works today, the CMS EHR ID can only be found on the "Grocery Cart" page and only after the <Get CMS EHR ID> button is activated.    One first selects their EHR product(s), puts them in their "Grocery Cart" and then goes to their <Grocery Cart> page.    The button becomes available when one has either:

• selected a certified Complete EHR product

                                     or

• selected a set of certified Modular EHR products that meet all of the certification criteria      

It interesting and helpful that CHPL provides real-time feedback when selecting a set of Modular EHRs.  Once all of the criteria are met, the <Get CMS EHR ID> button becomes available.  

Awareness Issue #6:    Regarding the modular option, the CMS certification process does not include integrated testing of all the possible permutations of Modular EHR sets that can be selected.    So even though a set of Modular EHR products may produce a CMS EHR ID on the CHPL website, this does not mean that the selected set of products were tested as an integrated unit.   This does mean that the physician or hospital who is in the EHR selection process should not depend on the CMS EHR ID to determine whether the selected products can be interfaced or work together.     Due diligence will still be needed to ensure all of the selected Modular EHR products are compatible.   

In other words, if you're goin' to the CHPL and gonna' get an CMS EHR ID, it's best to know your EHR partners well before purchasing and implementing them!