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Inbox Management: The Healthcare Version

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Usability of EHRs Meeting at NIST

I'm here in Gaithersburg Maryland today at NIST - where the clocks are always accurate.

The context is a "Community Building Workshop" on usability of Electronic Health Records.

Longtime Docnotes readers know that I've been thinking/writing/talking about this for a long time.  Most recently - I testified (pdf) to the HIT Policy Committee's Implementation Workgroup on this topic.  

It's impressive that this has come to be a compelling topic for discussion - but there remains quite a bit fo work to do.

Notes from today's meeting:

Jodi Daniel from ONC gave a nice little intro on ONC's rationale for being involved here.  Bottom line:  

1. As usability of EHRs improves - so does adoption and the effectiveness of EHRs in the delivery of value to the nation in the form of improved efficiency and quality. 
2. Let's work together to find the right solutions
   
   Jodi is super smart.  I'm alwasy impressed with her contributions to such conversations.  She is a listener and a learner - and I always know that she is thoughtfully incorporating what she hears into the policies that eventually make their way out of ONC.  Goot to hear her make the intro from ONC and it's good to see her so engaged.
   
   

Matt Quinn gave a good intro from NIST.  What NIST is - why NIST is engaged - and what is NISTs role in this work.  Like Jodi - I've grown to know and respect Matt of the the past few years.  His pitch:

David Brick, a cardiologist from NYC gave a well-intoentioned talk on some problems he's onserved in EHRs.  He provided examples of how EHR-derived growth charts can cause both displeasure and safety problems.  David's keystone example was a system in which a 5.5 POUND patient's data could be expressed as 5.5 KILOGRAMS when a user toggles between Metric and English systems.  While I agree there is a usability issue here - his  example is a bit of a straw man.  As one considers the continuum of user experience from functional - through usable - to meaningful - this example isn't even functional.  It's flawed deign - or falwed implementation.  Period.  It's a bug that needs to be fixed.

So while one might argue that this is ALSO a usability issue - we need to be careful not to lower the bar so much that such examples become part of the usability conversation.   Would user-centered design have prevented this flaw?  Sure .. but I would suggests that we need to assume or even demand functionality in this conversation - and sink our teeth into usability -  the next hurdle that the industry needs to jump.

Ben Shneiderman from University of Maryland up next.

    Ben is a dynamic and outspoken speaker on these topics.  

He describes the industry leading works of several vendors such as Apple.  I recall the early Apple usability guidelines well - and Ben makes a good point that design guidance is a good thing.    But should an industry have design requirements?  He doesn't go so far as to say that - but he actually comes rather close.

Ben makes a set of suggestions:

•     EHR developers should publish a set of EHR usability guidelines
•     EHR developers should permit examination & discussion of products their products by researchers
•     EHR developers should report on usability study results - so that others can understand strengths and weaknesses of these products and design teams.
•     EHR developers should promote consistency with industry-led common user inerface guidleines
•     EHR developers should report failures periodically with common metrics
•     EHR developers should work with government agencies to coordiate sspceficif industry practices ..

Ben expressed frustration that vendors have not shared with him any examples, access to demonstration systems without signing NDA, access to documentation, or even details screenshots of EHRs.

Ben is a passionate and articulate guy - and his heart is clearly in the right place - but it's simply not all so simple as he portrays - and I would argue that the vendor community may not be so cooperative with him as he would like - because his demeanor is combative rather than collaborative.  How can one trust that a collaboration with Ben won't turn into a marketing tragedy?

Next up ... 

Mohammed Walji - SHARP-C

SHARP-C is an ONC-sponsored grant program @ UT - Houston.  I was an advisor for the project for a while - and I find it to be incredibly interesting - yet somewhat academic and therefore not quite ready to inform the industry.  Yet.  Perhaps they will at some point and that will be valuable indeed.

Mohammed outlined a general approach that their team is taking to usability:

TURF framework for usability:

1. Task
2. User Representation
3. Function

 

 

Facets of usability:

1. Useful - Satisfying - Usable
2. Intrinsic complexity ==> Usefulness
3. Extrinisc complexity ==> Usableness

 --

Arien Malec from ONC - descibes the successful method that government and industry worked togethersuggests that a process here enables us to:

Raise objections and concerns early in the process

Ensure the resulting usability test approach supports multiple modalities (eg dicataion)

Learn from each other and creat UX and design best practice that create superior usability and UX

Concern:

Measurement may not capture the nuances of heatlhcare

Reply: Help us define the instrucments and measurements and methodilogies

ONC suggests that the community can help define the workflow and context - sensitive tests

 "vendor community says: don't let he government tell us what is good or bad - we want the market to tell us what is good or bad"

Users "we don't want the govt to incent us to use stinky software"

Community - not ONC - can define what this is - through the (proposed) Marketing Usability Workgroup

1. Share end-user and vendor concenrs
2. Define emchanisms to endusre an deffieicne and wwell dunctioning marked
3. Supply relevant and accurate information to end users
4. Reward excellence in ux
5. Spur innovation

Workgroups comprised of:

- academic researchers

- vendors

- Users / Implementers

- Government

- Human Factors professionals

Edna Boone - HIMSS

Speaking about advantages of professional collaboration community.  Good dovetail with Arien's talk.

Usability industry - Human Factors, Design and Usability people .. 

Proposal:  A community of profession led by HIMSS Usability Taskforce - responsible for providing domain experttiese, leadership and guidance to activities, inittiateas and collaboration within the speciality of HF, usability and design ..  

Ron Kaye - FDA devices human factors guy - here to describe how FDA manages human factors issues in the medical device arena.

 

Jorge Ferrer - VA

Jorge provided an interesting literature review on recent papers that have been published in the domain of usability - and focused on a usability framwork developed at the VA - with a (too long to for me to trascribe) list of recommendations for "next steps" in usability in HIT.

 Janet Campbell - Epic

"What are the needs of software developers?"  

Usability is a journey rather than a destination.

We are not (nor will we ever be) perfect.

"Our users are smart people.  Physicians have hig standards and low tolerance for dysfunctional design."

What do providers need?

1. Safety 
2. Empowerment - customization of a user experience FOR ME
3. Adapt systems to changes or external requirelents.  Systems need to be flexible and adaptable.
4. Disabilities should be understood and anticipated (accomodate poor vision or bad mouse skills, etc).

Dialogue between user and vendor is fluid and useful.  When a third party gets involved in the conversation - it make it more complex - and sometimes the messages get less clear.  

Concern about measurement, guidelines, standards .. measuring things that are un-measureable .. or comparing systems to some sort of idealized design.  There exists a public-private partnership that is working.  There is an unspoken message here that the industry has failed.  In fact - it has not.  Is the government barking up the wrong tree?  Aiming to solve a problem that isn't in its scope to solve?  A government assessment may send the message that a certain design standard will meet the needs of all users.

We think there is a role for ONC and NIST - let's look at the common requirements - as defined by Meaningful Use - to see how we can optimize THESE processes.

 Mary Kate Foley.  VP for User Experience at athenaHealth.

Educate, Motivate, Improve.

Mary Kate describes the challenges of implementing UCD principles in an organization that previously didn't use them.

Observations:

    EHRs lag in usability

        Inhibits adoption

        Inhibits productivity

        Contributes to clinical risk

AHRQ report on EHR vendor practices and perspectives

Market factors will exert appropriate pressure 

Can we anticipate and acellerate?

Apply our UCD principles to the problem - how can we do more UCD @ EHR vendors?

    Understand the problem.  Complex needs, complex user bases.

    Focus on the target audience

        Usability maturity:  

1. Low (don't know what they don't know - no champion but may be skeptcs .. and misguided enthusiasts)
2. Medium ( a few practitioners - org still learning - many skeptics .. still some misguided enthusiasm)
3. High (ux recognized as a llever for business performance.  experienced dedicated ux people. team .. integrated with RND) .. Employ reliable UCD patterns.

Design with tartget in mind

Low - Educate

Medium Educate & Motivate

High - Motivate.

Get each vendor started where traction is likely to be greatest within vendors:  usabilty TESTING .. 

  -- 

Lyle Berkowitz

 
Shows the usability periodic table from HIMSS (see page 3 of this document)

Practice guidance:

• Engage your users from the start (not just  the physician geek).
• Consider the practice goals
• include ux questions in your RFP
• Perform usability tests when evaluating new software
• Observe other practices using the products
• Discuss findings with the vendors

--
Work has units .. Clicks .. Time .. Eergy. Effort, frustration, failure .. 

 

Lana Lowry - NIST

Bob Schumacher, User Centric

Emily Patterson, Ohio State

Bob North, Human Centered Strategies

Chris Gibbons, Johns Hopkins

 (editorial:  I like Lana - I think she is a bright, passionate advocate for doing things right.  Her slide deck, however, was the worst of the day.  It violated nearly every principle of a "usable" presentation.  She needs a copy of Presentation Zen.  I think I'll buy her a copy.  No kdding.

Lana's presentation was the first of a few sessions that got to the meat of why we were all here.  All of the previous sessions were (I think) meant to set a level playing field and make sure that the audience was all on the same page (what is the definition of usability, etc) and had been exposed to various perspectives on the matter - HF experts, government folks, vendors, etc.  In general - this worked - but it could have been done much more effiiciently.  We could have had 2 hrs of intro rather than four - and I would have preferred to spend much more time on the "meat" of the matter rather than just a few quick presentations in the afternoon.

Proposed EHR Usability Evaluation Protocol 

These presentation (I'll post later today in more detail about them) focused on the EUP and what it is.  Key message:

a) EHRs should be tested by people with advanced training in usability, human factors, cognitive science.

b) The focus should be on testing for errors.  The key here is patient safety

c) There will be a collaborative community effort that is created to define the details 

 

 

Health Protection and the role of HIT

Health Affairs arrived in the the mail today.  

I pulled it open like an excited kid opening a birthday gift.  Despite my affection for all-things-digital, there is something to be said for propping my feet up on the coffee table and reading insightful work on important subjects.

This paper describes a compelling story that I'll try to paraphrase - as it introduces the concept of PROTECTION that  I'd not previously considered.

The authors consider three possible interventions to improve the health status of a population:

• Coverage (increasing the scope of insurance coverage)
• Care (facilitating providers and patients to follow best practices for preventive and chronic care)
• Protection (enabling healthier behavior and safer environments)

The paper describes the results of a modeling exercise in which a population receives one, two or all of these interventions.  The results predict that expanding coverage would result in modest improvements in health status and cost, Coverage PLUS Care results in better health status and reduced cost - and (after a 3 - 5 window of increased cost) Coverage + Care + Protection results in MUCH better overall health status and reduced cost.

So what?  This study reminds us that:

a) Expanded coverage is not the only answer.  In countries with universal coverage - we see good validation of this unfortunate reality.

b) Better care is also a necessary but incomplete solution.  

c) The hardest part - and likely most essential - is that we need a cultural shift in how we can create and maintain a healthy environment.  

How do we get there from here?  

My intuition is that we treat the nation (globe) as we would an addict.  We have become addicted to certain behaviors that we know to be destructive.   Yet we continue.  Smoking, obesity, lack of exercise, over-eating ... these are all key components of our addicted nation.

Years ago, I became impressed with the work of William Miller, Marian Stuart,  and James Prochaska - and used their techniques successfully in my practice.   The common thread is that we understand and support our patient's interest in following a path toward better health.  This is terribly hard to do in a manner that isn't judgmental.    But when we judge ("this is bad behavior") we alienate the patient - and make collaboration more difficult.  It is only when we are open to the outcome - but not focused on one outcome in particluat - that we collaborate toward success.

So when the patient is a globe or a nation or a community - how might we mive forward?

a) Recognize and reflect.  "Is this how you want to be living?  Is there anything you would like to be different?"

b) Celebrate Success.  "How have you been successful in the past?  What might you try again in the future?"

c) Offer tools and support.  Reminders, suggestions for alternatives, skill-building.

I often notice that many communities have built such traditions that they don't even know how to behave differently.  

In our industry - HIT - I think that be most productive use of our time is to focus on (c) - so that we can help providers and patients collaborate (a) and (b).  

e-Communication with patients

Readers have started asking me about my new company ... 

Perhaps the change to my LinkedIn profile was the tip-off  :-)

While we're not quite ready to publicly describe what we're doing, I CAN say that our focus is on creating great tools that providers and patients can use to communicate.

While e-communication has become pervasive globally - it has not become part of the routine in healthcare. I met with a colleague for lunch last week - and she described the pile of paper faxes and letters she receives daily from other physicians. She communicates with patients using e-mail "only rarely - for a small number of patients" and even limits phone calls as much as possible - delegating them to a nurse.

A face-to-face visit in the office remains a cornerstone of communication between patients and providers, and the fax machine remains the preferred route of communication between primary care provider and specialist.

Will this change? Of course it will. That's the bet we're making - and I don't think that it's a scary bet at all. e-communication between patients and providers is better, and it doesn't take longer.  Provider satisfaction improves, patient satisfaction improves.  Everyone is happy.  Right?

Well .. no.

The key barrier here is ... money.  HIMSS did a survey and found that lack of reimbursment was the key barrier.

Doug Fridsma (Long before be went to ONC) did a study way back in 1994 and found different barriers and a remarkably high level of use.   Back in 1994 - it seemed like we were on the threshold of an explosion of e-communication.  Why didn't it happen?

a) Insufficient financial incentives.  Yes - I believe that lack of reimbursement is a key barrier.  In places where this is part of a provider's job - the use of e-communication is pervasive.

b) The tools stink.  I'm tempted to use a stronger word - but I won't.   AOL (You've Got Mail!) didn't evolve into Facebook.  AOL (and others) have been disrupted by Facebook.  The existing software for this sort of communication was built long ago - and it simply didn't anticipate the needs of 2011.  You can't build a skyscraper on the foundation of a four bedroom colonial.  The current tools will not survive.

c) Timing.  With the exploding interest in mHealth, and the ubiquity of communication devices - we now have methods of connecting that weren't imaginable ten years ago.  As PCMH experiments such as those at Group Health Cooperative and others demonstrate - it's BETTER CARE to keep patients out of the office and out of the ER.  One way to do this is to increase our availability.  With much more data available - we should expect to see more payers experimenting with reimbursement models that are inclusive of e-communication.  Is this a PCMH pilot?  An ECO experiment?  We'll have to see.

So at Twistle - we're honing in on what we think will be the best software solution to help solve these real problems.   I've launched a 30 second survey to help us understand which specialties might have the most interest in using a new solution today - even without reimbursement changes.

Since I'm a family physician - I think with my "primary care" hat on by default.  This isn't good.  I need to try to pretend to be a specialist sometimes.  So I schedule myself to spend time with other physicians on a regular basis so that I can better understand them.   As this study demonstrates,  in 2008,  there are interesting patterns:   21% of female physicians e-mail with their patients vs 19% of men.  19% of primary care;  24% of specialists.  28% of those in a multispecialty group vs 17% in a single specialty group.

Why would a specialist be more likely to e-mail her patients than a primary care physician?  One answer we're hearing a lot is "opportunity cost."  Even though the providers aren't paid for the e-communication - a specialist's opportunity cost (especially a busy procedure-centric specialty) is significantly higher than that of a primary care physician.  So if a busy gastroenterologist can e-mail with six patients in 20 minutes - and keep those six patients out of the office - then she has time to do one more colonoscopy!

This differs from the attitude of my family physician friend - who feels that she needs the face-to-face visit for all conversations - as she fears that e-mail would otherwise consume her day - without any reimbursement.

Much more to think about here.  Please do take the survey and pass the link along to your friends & colleagues so we can get some good data.  I'll share the results here in a week or so.

Thinking Beyond Health 1.0

"Listen to what the young ones are doing/thinking" is often the guidance of "Innovation Gurus."  Facebook started with them college kids.  Teens texted enthusiastically well before The Rest of Us.

So I went and did my occasional "Medical Informatics" class this morning with the 3rd year students at Albany Med,  and I was surprised by how their education has caused them to think so inside the box.

I recounted Eva Powell's testimony at yesterday's hearing in DC.  Eva had "pink eye" and recounted a several-hours process of getting to the physician, getting a quick look ("yep - that's what it is") and leaving with a prescription.  She asked why a cell-phone camera click .. a short review or conversation with the doc - and an e-prescription couldn't be a more efficient method of managing this problem.

Well of course it could.  Yes, yes .. I hear you doctor scaredypants ..  there are nuances to the diagnosis of pink eye - and the differentiation between viral, allergic and bacterial causes may or may not be so easy on the phone or FaceTime but let's not worry about the details here...   The question Eva appropriately asks is "WHY IS THE HEALTHCARE SYSTEM SO SYSTEM-CENTRIC?"  (ok .. she didn't shout) and she is right.  It's easier for the physician to sit in the office and have patients come to us .. and of course the reimbursment models motivate us to "bring patients in" rather than consider ways to behave in a more patient-centric way.

To me - this is all self-evident.   We SHOULD think outside of our box, work to define new models of care that meet them where they live .. and (duh) use technology to bridge the gap.  

I had breakfast yesterday morning with e-patientDave and he asked me if I had heard of "Shared Decision-Making."  Dave is a wonderful guy - and a great spokesperson for patient-centered care .. and he does a fantastic job of asking the "dumb questions" that we all forget to ask sometimes.  "Yes" - I calmly replied (letting him make his point) .. as I thought to myself .. "DUDE! .. SDM is the CORE of Family Medicine Education! .. It's the CORE of what I believe to be RIGHT about how many providers work with our patients ..  and I've blogged about it for TEN YEARS!

[Fact-check: It looks like my first post here on the topic was nine years ago.  oops].  

So I agree with Dave that we need more shared decision-making .. and I agree with Eva that we need to behave generally in a more patient-centered way.

And so I was surprised when our medical students thought about all of the reasons NOT to help Eva get the care she needed without driving about Washington DC.  They defended the status quo:

"liability"

"risk of wrong diagnosis"

"I need to see them in the office in order to get paid"

"I need to see them in the office in order to write a prescription"

 ... and so on.

I galloped across the front of the room and asked what they heard.  "a Zebra" said one.  

He was almost kidding.

These folks have learned to fear the zebras .. and behave accordingly.  

So over the course of the next fifity minutes .. we talked about the possibilities.  

What if ... computers could do X to help the patients? What if everyone coudl practice like Dave & Barbara?

What if ... 

And they started to stop thinking like carbon copies of the white-coated educators who have been "teaching" them for the past three years - and more like the TwentySomething iPhone-carrying creative Thinkers that they are.

They have an assignment to think outside the box for the next few weeks and draw a picture of what they see.   I'll update you on what happens.  

Where does good come from?

Dr Wilson is in the news again.  I've always been drawn to his work.   My Division I work at Hampshire College in 1983 was on social spiders - and I found that E.O. Wilson had done much of the research on the subject - despite his "claim to fame" in the domain of ants.

Spiders have a reputation for being a solitary lot - and some female spiders eat their mates after they are "finished."  Yet other spiders like each other - and for some reason - as a reasonably solitary college student in 1983 - I was drawn to this work.  

Now Wilson questions some theories that he supported for decades - and he's creating a big stink - alienating many of his former colleagues.  

But to me - his stuff just makes sense (again).  The base of the argument seems to be that the prevailing theories (with mathematical "proofs" that are waay over my head) support species' (including humans') predilection to do good things for relatives - even if it means self-sacrifice - but not for those with whom we are unrelated.

Wilson's current argument is that we needn't be related to form a group with whom we compete with other groups .. and we will "do good" for OUR group - even if it's not comprised of our kin.

I don't get why that's so controversial.  I've not read the science here - and I am sure that there is a pile of data from ants and monkeys and turtles that support this hypothesis.  But there's a lot to reflect on human history where these theories are borne out as well.

As I look at health care - both in the US and elsewhere - much of what defines the most successful people is the right balance of selflessness and self preservation:  we need to think and act beyond ourselves - and focus on the needs of the population - yet if we think TOO selflessly - our efforts are not sustainable.

Kin are convenience groups - since we have good connections with them - for a very long time.  But I would agree with Wilson that IN ADDITION TO (not instead of) our kin - we can/should/do perform "good" acts for others for the sake of being good.  This is not about "getting something back" - and now there is at least one famous biologist who thinks there is a scientific basis for such actions.  

Amid the resurgence of Ayn Rand - and her nutty philosophy - I'd prefer to think of humans as inherently generous.

What is Quality?

February's Family Medicine had a great paper on the seventh element of quality: the doctor-patient relationship.

Key message:

The characteristics of quality are:

• Effective Based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse)
• Patient centered Respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions
• Timely Avoiding unnecessary waits and sometimes harmful delays for both those who receive and those who give care
• Efficient Avoiding waste, in particular waste of equipment, supplies, ideas, and energy
• Equitable Without inappropriate variations that are attributable to personal characteristics such as gender, ethnicity, geographic location, or socioeconomic status
• Safe Avoiding injuries to patients from the care that is intended to help them
• Relationships  Sharing meaningful therapeutic interactions with patients and other members of the health care team

 

Spring, EHRs, Connections ... Death

Wilson the Wonder Dog died this weekend.  He was eleven (we think).  This is our last picture of him.  He was a happy, energetic doggy until the very last moment.   Last week - he had a wonderful walk/run at the golf course - where he and hunreds of his doggy friends enjoyed a sunny post-snowstorm afternoon.  The spark in his eye and (yes) his smile was infectious happiness.

Canine angiosarcoma - like the human one - is agressive and unforgiving.  In Wilson's case - it was hiding on his spleen until it ruptured suddenly on Saturday morning.  Two hours later - I was digging a very deep hole in the woods of our back yard.  

There is something fogiving about sudden death.  For Willie - it meant that he didn't suffer much at all.  But it didn't give his family any time to prepare for his absence.  Since I work from home most days - my world has become very different.  No barking (our other dog, Mookie has become very quiet) .. no tail-wagging .. no "hey dad can I go outside again" whines.  Just quiet.

So I look outside .. watching the latest snow deposit melt .. hoping for Spring and the lightness-of-being that seems to come as the windows open and new life emerges.

2011 has already seen many new things for our family .. not the least of which is that I resigned from my role as CMIO of one of the country's most successful EHR vendors.  This was a deliberate - and very carefully considered decision.  I did not ESCAPE from Allscripts.  Indeed - I learned an enormous amount there - and enjoyed my work very much.  So my move was more about going TO rather than going FROM. What I went TO was a small venture with a small, focused team - and big ambition to help patients and care providers collaborate.   

 

Sammy Starts a Business ...

With some help from Nikita - the offshore development leader, Sam is on the edge of releasing his first website.  While it's not likely to cause him to be the next Sergey Brin - he hopes to make a little bit of money - and provide a valuable service.  Details to follow in a few days when version 0.5 goes live ...

Sam needed to create an LLC.  When we created Oncalls.com about a decade ago - we did a quick google search (maybe it was Altavista back then!) and chose a company that could "take care of creating a company for you" for a low-low price.

But the low-low price we paid got us stuff we didn't really need (a special seal, a binder with 10 pages in it, an annual fee for a Registered Agent, etc.

So this time - we used UpstartLegal.   They do what you need (help fill out the forms and file them with your State and with the IRS - and don't do what you don't need.  Most of the companies that you find on the Internet will charge you more for filing with your state - and they generally include registered agent fees.  But if you create your LLC in your home state - you don't need a registered agent.  So even though they may have a low-low price of $99 - when it all comes together - you'll end up paying much more than that .. and more every year thereafter.

The UpstartLegal team is smart, honest and very clear.  It's a nice service that made this part of Sam's new endeavor completely painless and worry-free.  Well done. 

EHR Incentive Program Registration Instructions

Registration opens today for the EHR Incentive Program.  The process is not so easy as one would like.  Here's an overview for how to register as an Eligible Provider.

1. Go to the Registration Program's login page.
2. You need a login.  This is your NPPES login.  Oh?  You don't have one?  Neither did I.  
3.  I do have an NPI.  So do most EPs.  If you have an NPI - you can create an NPPES login here.  If you don't have an NPI - you will need to apply for one here.
4. OK .. go back to the login page (link in #1 above) and log in.
5. Click on "registration"  (the tab at the top) and scroll down to the bottom.  Your name is listed and at the bottom-right is hyperlink:  "Register."  Click that.
6. Click through to the page that is going to stop most providers in their tracks.  There are several questions:  First - you need to select whether you are participating in the Medicare or the Medicaid program.  You should know.  Most providers will choose Medicare.  This next part is counter-intuitive:  you need to select the radio button - and then click "apply."  It's terrible design.  What does "APPLY" mean?  Am I applying for the program?  No.  In this case - what I THINK the web designers meant was that you are APPLYing your selection of the radio button.  When you choose "Medicaid" - a drop-down list appears so that you can choose your state.  Only a handful of states have competed their paperwork - so only a handful of state Medicaid programs are open for registration.  If you plan to register for the Medicaid program in one of the states not listed here, you need to wait days, weeks or months until the program is active.  There is a link to this page (ugh! pdf - more bad web design - here's a non pdf version) that lists the state programs and their expected ETA.  Don't know which program you qualify for?  Use this nice wizard to figure it out.
7. Once you select the program - you are asked whether you have a certified EHR - and if so, what the certification number is of that product.  This is an OPTIONAL question.  I assume that's because some products are not fully certified yet - or because in many scenarios - one needn't even have an EHR yet.  This is just registration for the program.  Note that this page requests a certification NUMBER but in fact - what they want is a "YOUR CERTIFICATION ID" - and NOT the "Certification # of the product.  Yes - this is confusing.
8. This page directs you to the CMS website here.  But that's not the right place to go.  What you need is the CHPL - the Certified Health IT Product List.  To create your certification ID (you don't really need this - recall that it's optional)  .. go to the CHPL here .. then browse the list or search for your vendor(s).  The second column is the PRODUCT's certification #.  Not what you want.  If you have one complete EHR - click on "add to cart" and follow step #9 below.  If you have several modules - add all of them to the cart.
9. At the top of the page - you will see a link to your "shopping cart."  Click on that link.  Now you see your list of modules.  You need 100% Certified EHR technology - so if you have modules that don't make you "complete" - you won't be able to create a certification ID.  Have 100%?  Great.  Now click.  There is your certification ID.  That's what goes in the optional field on the EHR Incentives registration page.  Let's hope they fix this soon so that it's more clear.

I didn't get past this page - (yet) as my state isn't one of the active ones - and I will apply for the Medicaid program.  If you got past this screen - please let me know if you encounter anything challenging.