Some of the best and most objective information about EMRs comes from the Center for Health IT at the American Academy of Family Practice. Real doctors who have purchased EMRs rate their EMR in 5 different categories: Quality, Value, Usability, Productivity and Support.

This report is ONLY available to members of the AAFP. I think if the AAFP really wanted to do all of us a big favor, they would release this report to anyone who is interested in seeing it. I don’t understand why they are keeping it secret.

It is going to be very difficult for doctors to find a good EMR because there are so many EMRs and so many “bad” EMRs (hard to use, reduce productivity, expensive). Starting with this survey can help doctors start their EMR search on the right foot.

Contact the AAFP and ask them if you can get a copy of their report.

Center for Health IT

Hopefully they will have our great Healthcare System’s best interest at heart. By making this report available to all doctors, they can help us all get “good” EMRs that are usable and high in quality.

If you are a doctor looking for an EMR, start your search with a few EMRs that get good ratings in this survey.

I just read Ryan Rick’s guest post on Phoenix, Arizona EHR Uninstalls and I remembered a New York City Health Department’s project called Primary Care Information Project (PCIP) headed by Dr. Farzad Mostashari. I see big problems for Dr. Mostashari’s project. I predict many uninstalls and ultimately a low successful implementation rate. They have good intentions but are making classic mistakes which will ultimately prove to be their undoing. I hope what they are doing will work (because I am a big fan of EMRs), but let me outline a couple of critical weaknesses in their plan and then we will see how things work out for them over time. I think all “top down” EMR implementation organizations will take note of this experiment.

I think Dr. Mostashari has bought into the notion that implementation has to be daunting and hard. “Our experience here is that it’s just hard,“ Dr. Mostarshari said. He thinks like Dr. Middleton, “A crucial bridge to success, according to experts, will be how local organizations help doctors in small offices adopt and use electronic records. The new legislation calls for creation of “regional health IT extension centers”. In a letter to the White House and Congress last month, Dr. Blackford Middleton, chairman of the Center for Information Technology Leadership, a research arm of Partners Healthcare in Boston, and 50 other experts emphasized the importance of these centers and pointed to the Primary Care Information Project in New York City as a model.” — Steve Lohr, How to Make Electronic Medical Records a Reality, New York Times, March 1, 2009.

Implementation is daunting and hard if you pick systems which are NOT simple, NOT easy to install, NOT easy to learn, and NOT easy to use. PCIP in New York City is using eClinicalWorks which has a good reputation, but I am NOT sure it is simple, easy to install, easy to learn and easy to use. If eClinicalWorks had all the “simple and easy” characteristics, then I don’t see why the implementation would be so difficult and daunting.

Dr. Mostarshari is also moving very aggressively and fast. Not a good idea in my opinion! He is rolling things out to the whole system before seeing what works and what does not work. “The city Health Department’s Primary Care Information Project (PCIP) has already converted over 1,300 physicians and 226 medical practices to EHRs”. Record Recovery, Center for an Urban Future, page 5, June 2009. www.nycfuture.org. I think the project is only a couple years old.

Ryan Ricks, of XLEMR, makes a series of suggestions in his post which I believe are extremely important. “It seems that Arizona physicians are scrambing to remove unusable systems due to poor selection or botched implementations.”. “Physicians need to be careful and not rush into a decision they may regret.”. “Physicians should focus on their needs … and select the simplest system that fulfills their requirements”. “Simple systems are easy to install, easy to learn, and easy to use.” “Ease of use is critical; complex and difficult systems can lead to spiraling maintenance and training costs, and may ultimately be discarded”. “They should take their time to find a simple, user friendly system that meets their needs.” — Ryan Ricks, XLEMR Update Newsletter, July 2009, www.xlemr.com. Mr. Ricks makes some excellent points. Water flows downhill very nicely, but it takes a lot of energy to pump it to the top of the mountain!

It is my feeling that implementations would be less daunting and more successful if the EMR systems were less complex, easier to install, easier to use and easier to learn. Doctors are smart people who can learn to do stuff without handholding and constant supervision and oversight. The fact that the New York City PCIP Project needs all this hard work and all this effort and all this money makes me suspect that they have made major mistake in choosing an EMR system that is too complex, too hard to learn and too hard to use. Their second mistake is moving very rapidly to roll it out to the whole system before removing the bugs (the bug may be eClinicalWorks).

This top down approach is doomed to fail. Doctors must be able to choose the systems which works for them. If you have to ram it down our throats, it will be regurgitated at some point when we just get fed up. This happened in Pheonix Arizona, is going to happen in New York City and, if we are not careful, may happen in the whole country if things are not managed in a smarter manner. This is also a warning to Hospital Systems which are working in a similar “top down” manner to provide EMRs to their employed physicians and their private physicians (via the 85% rebate model). We don’t need Regional Health IT Extension Centers and we don’t need large organizations forcing us to use THEIR preferred EMR. We need to be using EMRs which are easy to install, easy to use and easy to learn! We need to identify those EMRs and promote them aggressively.

In Washington, where partisan bickering over how to revive the economy flares on several fronts, sweet consensus reigns of heath-tech spending … lawmakers cheer electronic records as a business-based remedy for much that ails medical care … That rare agreement, however, is obscuring the checkerboard history of computerized medical files and drowning out legitimate questions about their effectiveness. Cerner, based in Kansas City, MO., and other industry leaders are pushing expensive systems with serious shortcomings, some doctors say. The high cost and questionable quality of products currently on the market are important reasons why barely 1 in 50 hospitals has a comprehensive electronic records system, according to a study published in March in the New England Journal of Medicine. Only 17% of physicians use any type of electronic records. – Chad Terhune, BusinessWeek, May 4, 2009, The Dubious Promise of Digital Medicine: Why huge spending on electronic records won’t produce quick improvements in efficiency or care.

I have to agree with the above assessment.

“Industry leaders are pushing expensive systems with serious shortcomings” and
”The high cost and questionable quality of products currently on the market are important reasons why” … many hospitals and physician groups do not use EMRs.

I am interested in hearing your opinion on this matter. I believe that there are great systems out there. Why are they so hard to find? Why aren’t doctors finding them, buying them and using them?

I turned on the radio on Monday and they were talking about Healthcare again. Universal coverage, the August recess, the “blue dog” democrats.

I keep thinking about how EMRs fit into all of this. Obama thinks that EMRs are going to make care better, more efficient and less costly. I think he is right about the first two (if we install EMRs that are usable and bring value to doctors and patients), but not necessarily about the third. EMRs may not reduce costs!

As Obama takes our economy (and our healthcare system) away from the small business model to the big government/big business model, I wonder how EMRs fit into all this. Investing in an EMR is a big deal for most physicians because we are a small business that provides medical care. Spending hundreds of thousands of dollars on an EMR which may not bring return on investment (ROI) while potentially reducing our productivity is a big risk. At the same time, if reimbursement are reduced or the system becomes Universal, the stakes are higher and the risks are greater.

Everyone (individuals and small business) is struggling with our current economy. Small businesses are at risk (many are closing their doors). Physicians are working hard to pay the bills, make payroll and have a little left over to take home to the family. The EMR issue has to be handled correctly or it could have dramatic effects on our healthcare system. The EMRs have to be effective and efficient. Doctors have to like them and be satisfied with their utility and performance. EMRs have to help us take care of patients more effectively and efficiently. Anything less than this throws more sand into the cogs of the healthcare machinery and amplifies the risks of all the other changes occurring at this time.

Because of all the money being thrown at doctors and hospitals as part of the HITECH (Health Information Technology for Economic & Clinical Health) Act, a component of the ARRA (American Recovery and Reinvestment Act), it becomes important to use certified EMRs in a meaningful way.

It has always been important to use EMRs in a meaningful way, but now you can get paid ($44,000 per physician) if you jump through hoops created by organizations like CCHIT which is the Certification Commission for Healthcare Information Technology, who want to make money for their executives and suppress competition for their top clients. The government has put the wolves in charge of guarding the hen house. Diversity, choice and competition have taken a back seat to self-serving regulation based on big business payoff of our government at its highest level (the big EMR companies have bought Obama). This is truly breathtaking and incredible (see BusinessWeek May 4, 2009, page 31-37)! The best way to stunt the development of any system is to suppress diversity, choice and competition by putting the rich and powerful in charge. The people in charge want to make more money, they don’t want better EMRs and they don’t want what is best for our healthcare system.

Today’s blog is going to be a little different. I am not going to comment on the present criteria used for CCHIT certification and I am not going to comment on the current state of the “meaningful use” definition. I KNOW what “meaningful use” is. I am a doctor, I have an EMR … I know “meaningful use” when I see it. Walks like a duck, quacks like a duck, looks like a duck. All doctors KNOW intuitively what “meaningful use” is.

I am not going to comment on the specifics of CCHIT Certification Criteria because I KNOW it is not optimal. Tear it all down and let’s start from scratch. It may have served a purpose in the past to move the industry forward, but it has now become a problem. It inhibits innovation, diversity and choice. It costs too much, it is too complex and many very good EMRs are not CCHIT certified. Company’s are wasting their time, money and effort to get certified rather than improving their EMR product! CCHIT’s primary purpose now seems to be self-preservation at any cost. Their executives want to preserve their six figure incomes at any cost.

Instead of commenting on what others have said about these two issues, I am just going to tell you what I think … I am going to keep it simple.

Any EMR that can be used in a meaningful manner should be certified. Period. End of the certification problem. My definition of meaningful use is so simple and so intuitive that certifying an EMR becomes very easy. So easy that you don’t need to pay much money and you don’t need an organization like CCHIT. You can hire a CPA or an Accountant to do the certifying.

Any EMR should be certified if it can do everything listed below. If it can do these tasks, it is being used in a meaningful manner and thus satisfies the “meaningful use” requirement.

What an EMR must do:
●Document a Progress Note
●Store, Index and Provide access to Lab Results, Test Results, Hospital Reports and Consultation Reports
●Store and Track Wellness information for Chronic Conditions like Diabetes (Fasting Blood Sugars, HgAICs, Eye Exams, Kidney Tests and Foot Exams) and Coronary Artery Disease (Blood Pressure, Cholesterol, EKGs, Stress Tests, Echocardiograms, Catheterizations, Cardiac Consultations).
●Store and Track Health Maintenance Information for Routine Care of Adults and Children (Flu Shots, Pneumonia Shots, Immunizations, Mammograms, Pap Tests, PSA, Colonoscopies, Bone Density Tests)
●Write Prescriptions
●Write Orders
●Help Select Diagnosis Codes (ICD-9 and CPT Codes)
●Help Select Level of Care Codes (Evaluation & Management (E&M) Codes)
●Perform Scheduling, Billing and Intra office Messaging OR Interface with a Practice Management System
●Collect and Report data for Quality Improvement Activities and Pay-for-Performance Activities
●Connect with Regional Health Information Exchange Platforms (HIE Platforms) AND be able to Import and Export Data in the Continuity of Care (CCR) or CCD Format

If an EMR can do the above tasks then it is being used in a meaningful manner and it should be certified. My background is Internal Medicine, so there may be adjustments that are need for certain specialties. Some may feel that I should include a patient portal and clinical decision support in the above criteria.

Let’s not overcomplicate this EMR thing. We want doctors using an EMR and we want companies coming up with better EMRs which help doctors provide better, more efficient care at a lower cost. The only way to achieve these goals is to let the market place select the best EMRs. In order to do this, you need innovation, variety and choice. You have to nurture and support small companies. We have to encourage people to get into the EMR business rather than create barriers to entry. Using CCHIT certification and possibly a complicated definition of “meaningful use” we risk inhibiting innovation by snuffing out new and small companies with regulations that are not practical, helpful or wise.

This is a SHOUT OUT to all doctors who use EMRs. Which EMRs do you use and how do you like them. Do you love them or hate them? Are you luke warm in your like or dislike? Tell us which EMR you have and how you feel about it. Also tell us what you would do (the mistakes and the good moves) if you were looking into getting an EMR at this time.

I have personally looked at Greenway PrimeSuite, SOAPware, SRSsoft, e-MDs, AmazingCharts, NextGen, Centricity and others.

Can you comment on the cost and the usability?. Let’s share information so we can help other doctors choose systems that are usable, simple to learn, effective and efficient.

If you don’t have an EMR and are looking into one, what questions would you have for those “who have gone before you”? What advice would you be interested in receiving?

Hospitals are buying EMR systems for the Physician Groups that they own and they are allowed to pay 85% of the software and training costs for their independent physicians (physicians that they do not employ, but who refer patients to their hospital).

They are doing this for a number of reasons. It will improve communication for better and more efficient care and it will “connect” these physicians to that hospital (in multiple ways). Keeping the referral pipeline flowing is very important to hospital systems. This type of arrangement makes it more difficult for doctors to move their patients to other hospital systems and it builds loyalty.

Most hospitals are picking ONE system for their employed physicians and then they are going to offer to pay 85% IF independent physicians use this ONE system.

Although well intentioned (hospitals are trying hard to pick the best system for their doctors), I believe this approach is doomed to fail and will cause hard feelings and other problems.

Hospitals want all their doctors on one EMR system because of volume discounts and because they believe in maximal connectivity. Again, their intentions are logical and well-founded, but miss the mark.

Why will it fail? Because different doctors and different physician groups have different needs, different styles and different preferences. Doctors also need to be “masters of their own fate”, if they fail, they need to “own” the problem. In addition, hospital systems are only considering EMRs from the “big EMR companies” because they believe that “connectivity” trumps “usability”. When you limit your options to the “big EMR companies” you are choosing some of the least usable systems on the market.

Doctors need choice! They need to make the final decision on the system they purchase. Only they can find the best system for their practice and their practice style. One size does not fit all.

When the doctors become unhappy with the EMR software that their hospital chose for them (not usable, difficult to learn, decreases their productivity), they are going to become unhappy with that hospital system and their administrators. Since failure to implement EMR software is very high, we know this is going to happen not uncommonly. I anticipate lots of problems a few years from now. Let’s see how this plays out.

I am hoping that hospital administrators are smart enough to stay out of this EMR software trap. Give doctors a choice. Give doctors options. Don’t believe the big EMR company salespeople who tell you that you all need to be on the same system.

One Hundred Percent of Doctors and their offices use Practice Management Systems (PMS). Only 3% user “fully functional” EMR Systems. Why only 3% with EMRs and 100% with PM Systems?

The government is going to pay us $44,000 per doctor to use an EMR. They are going to give us a 2% Medicare bonus and other pay-for-performance incentives and they are going to penalize us in the future if we don’t use EMRs. In addition, hospitals are allowed to pay 85% of the cost of the software and training. Will all this money get us the use EMR? Can we be bought? Is it in our interest to use EMRs?

The CEO of SRSsoft tells us that this type of money is not significant if the EMR makes you less productive and less efficient. For example, if you bill $500,000 per year and your EMR makes you 10% less efficient, you lose $50,000 per year!

I agree with this CEO. We (doctors) will not embrace EMR systems until they are usable and they add value! “Usability is the effectiveness, efficiency, and satisfaction with which the intended users can achieve their tasks in the intended context of product use.” This definition comes from NIST, ISO and UserCentricity. Adding value means that it makes our jobs more enjoyable, shortens our work day or helps us provide better care.

Doctors use practice management systems because they are usable and they add value. Doctors do not use EMR Systems because most DO NOT add value and they are not usable. There are so many bad EMR systems on the market that the stench and confusion has caused many doctors to not even look (they ask their colleagues who have EMRs and these colleagues say “stay away, it is not worth the cost, aggravation and problems”).

I believe that there are some very good EMRs on the market. The challenge is to find them and promote them. If we (doctors) can find the good EMRs, word will spread and implementation will happen very rapidly!

President Barack Obama is defending his relentless campaign for a health care bill before Congress’s August recess, saying “the default in Washington is inaction and inertia.”

Mr. Obama, there is a good reason for inertia. It protects complex systems which have evolved over time from dramatic change which can be very disruptive and threaten the very survival of the system. Inertia moderates change so that change can be accomplished slowly and successfully. Inertia is sometimes a good thing. In the case of healthcare reform, this inertia might save our healthcare system.

Improving our healthcare system is an important project. This cannot be done in 3 months by politicians and bureaucrats who are not expert or experienced in the ways of healthcare. The system must evolve slowly, thoughtfully and carefully.

The goal should NOT be universal coverage at the expense of everything else! Universal coverage is a worthy goal, but there are other things which are more important like quality of care, cost of care, ability to access care, innovation and properly aligned incentives. Universal coverage puts EVERYTHING else at risk and therefore we need to pause, take a deep breath and figure out how we are going to improve our health system without ruining it and putting our whole economy at risk.

The experiment in Massachusetts has been a disaster. It has achieved the goal of universal coverage but the cost of care has gone up and access to care is terrible (not enough providers). Doctors are miserable, not making any money and they are leaving the state. Let’s look very closely at Massachusetts before we duplicate this disaster at the national level!

We keep hearing about the Big National Data Bank for Healthcare Information. The thought is that you need a big data bank so everyone’s health information is available anywhere/anytime. This type of personal health information repository has many problems. First it is complex and expensive to set up and maintain. Second there are very significant and well-founded privacy concerns. And finally, this large, complex electronic structure may not be needed … it might even be counterproductive!

Is there another way to transport patient health data from one platform to another (so it can go from one EMR to another), so that healthcare providers, anywhere/anytime can provide fully informed care for individual patients which would be less expensive and higher in quality?

I think the answer is YES!

There are standard data exchange platforms currently being used which can help us all share “meaningful” personal health information. They are called the Continuity of Care Record (CCR), CCD and HL7. For more information on these platforms, I suggest you read Brian Klepper’s blog post. This blog gave me great insight into this connectivity issue.

In addition to obviating the need for a big data bank, these data exchange platforms make it possible for small, innovative EMR companies to compete and survive in the “EMR Jungle”. By allowing for diversity and encouraging innovation, we will end up with better EMR software. In addition, physicians will be able to pick EMRs that suit their practice style and can make them more efficient, productive and better doctors. I think we need a patchwork quilt of unique EMRs that are all well connected rather than a few big standard lemming EMRs that are totally connected by “big brother” or “big business”.

What are your thoughts on this topic?