NOSH ChartingSystem

A new open source health charting system for doctors.

To certify or not to certify, that is the question…


As I’m planning the rollout stage of my project to interested developers and physicians, I am pondering the implications of certification for the NOSH ChartingSystem.   As a background, an electronic health record system has to be certified by one of 5 Authorized Testing and Certification Bodies approved by the Office of the National Coordinator for Health Information Technology (ONC-ATCB) so that a user (physician, practice, or hospital) of the system can claim for monetary incentives from Medicare or Medicaid when the system has demonstrated “meaningful use”.

These ONC-ATCB’s (the largest being CCHIT) ask for pretty hefty fees to test your system to get the certification, ranging between $20,000-$40,000.  Furthermore, as I understand it, the certification applies to the specific version of the software only, so if you have continued updates and modifications, you’ll have to re-certify your product.  No wonder most EMRs cost so much to the doctor – the costs likely get passed down to the doctor for the certification.

Furthermore, based on the HITECH Act that was passed in 2009, physicians who see Medicare patients and who do not use a certified EMR by 2015 will see a gradual reduction in payments (1% per year) as a penalty for not using a certified EMR.

In my own personal experience as a solo family doc, I used an EMR ever since I began my practice in 2004.  Unfortunately, I had a version of an EMR that was not certified and I wasn’t able to upgrade due to the significant increased cost for a certified product (being a primary care physician).   Looking at all the core standards that attest to meaningful use, my practice and system met all the standards, but I would not be able to claim incentives due to my EMR being uncertified.  Knowing that I was going to see reduced payments (with already reduced payments across the board from Medicare and insurance companies by not keeping up with inflation), I felt that the system was somehow rigged against me even though I “did the best thing” with electronic health records.

CCHIT then came out with a separate program (called the EACH program) for people with “legacy” systems that did not qualify for certification but if all the technology that was used in the entity met “meaningful use”, then they could alternatively certify the system.  Unfortunately, I got a heart attack with the price tag of “gasp!” $40,000 (that was more than 50% of my income!!!).

And so, regrettably to my patients, I opted-out of Medicare as I saw no light at the end of the tunnel.  (More about that at my other blog).  So now that I have my electronic health record system waiting in the wings, an open-sourced product with the aim of being low-cost to the physician, does it even make any sense to be certified?  Is the risk of Medicare payment reductions worth it for physicians wanting to use a low-cost system?  I also think (but I can’t confirm) that most physicians would rather buy a certified product just because it is.   But if an uncertified product was incredibly intuitive to use and that it would actually help their productivity so that they can spend more quality time with their patients and improve outcomes, would it offset the risk?

At this stage in the game, I obviously cannot afford to certify my product.   Even if I could afford to certify it one time (I was thinking of Kickstarting my project for the aim of certification), the whole concept of this type of certification is antithesis to the open-source way (updates, modifications, improvements, low cost).  But I think if there was a growing community of doctors along with like-minded computer programmers and developers who stand in solidarity against this rigged game and somehow these rules were reversed through political means or by sheer mass protest, I’m all for it!

What are your thoughts?



Author: shihjay

I am a family physician and previous medical director for a child abuse assessment center. I am now promoting my new electronic health record system (NOSH ChartingSystem) that I have developed and used for myself in my private practice since 2010 and now I want to share it to the rest of the doctoring world.

8 thoughts on “To certify or not to certify, that is the question…

  1. thanks for that important information, it is really helpful. interesting article!

  2. I think Kickstartr or MedStartr ( is the way to go. If this is as functional as it is beautiful than we should move forward so it can be sold to other doctors. I have a feeling that there might be other ways to cover the upgrade certification costs in the future. There are many, many doctors who do not want to join a clinic or hospital and see no other option. Telemedicine, and/or rural medicine, is one area that has a lot of potential. I would like to find a way to provide this option. I am looking at a HIPAA hardened, virtual server based, managed hosting environment and then selling slices to doctors. As the practice grows the cost can increase or maybe by employing a plugin system of functionality into the base nosh-cs would defray some costs for the future. I am looking at this code for future Drupal integration as modules are the way the system works. I know you are built on CodeIgniter and it is very clean. But having a basic core and modules opens up the possibility of granularity specific to each client in the future. (Rx Solutions [AllScripts, Rx, SureScripts, etc.], Importing/Exporting different file types [Dicom, etc.], and others.

  3. I see the HITECH act as throwing sand in a complex system; it WILL produce unintended consequences. Perhaps “certification” is just like the specialist dominated AMA; the ‘big players’ have their eyes on the “big picture” – market share, return to investors, growth, power, more and MORE…. of the same hi tech, high cost, non sustainable Disease Care Industry. No, none of these words apply to the ideal micropractice of medicine, nor to my patients.

    I am planning to recoup some of my ‘sunk costs’ in my ‘soon to be obsolete’ EMR with 1 attempt at meaningful use funds; and then; i will have to accept the Medicare penalties but I cannot warp my medical practice around “Meaningful use” like my part time receptionist (my only employee) said; “I thought what we were doing was meaningful – it IS to our patients!”
    So with open source i will not have another huge startup cost anyway.

    Certified or not – probably offer both flavors – let us choose!

  4. I need to to thank you for this great read!! I absolutely loved every
    little bit of it. I’ve got you book marked to check out new stuff you post…

  5. whoah this weblog is wonderful i like reading your articles.
    Keep up the great work! You know, a lot of individuals are
    looking round for this information, you can aid
    them greatly.

  6. Nosh is a great attempt to democratize the otherwise monopolized EMR/EHR market. However since practices are not usually faster enough to adopt the Open source solutions for reasons known and unknown, the challenge for open source EMR are that they need to be doubly competent in terms of usability, feature set and performance. That apart since we are handling a set of customers who are not all that IT savvy, the support required needs to be on a 24/7 basis to make any inroads into such a market.

  7. Carlos Villalta
    The cost of certification is a way to still continue being e cash cows of many more “vendors” based of payments that continue to be smaller from Government agencies. The need should be for the Medical Business and Medical needs as determined by the Medical community. The cost I am opposed as is TOTALLY unnecessary. Am Pediatrician.

  8. Now with new President and new in charge maybe a certification process can be eliminated and the medical community should develop the features that would make an EMR of benefits to US and the patients NOT to the LEGAL SYSTEM and Bureaucrats.

Leave a Reply to Peter Jose Cancel reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s