I’ve been writing about the various open source EHR software options for about 5.5 years right now. I’ve been intrigued with open source for much longer, so it just made natural sense for one of the first things for me to look at would be the various open source EHR options.

5.5 years ago the open source EHR market (although EHR really wasn’t in vogue yet back then) had a solid foundation, but still had quite a ways to go for it to be a great option for doctors interested in an open source EHR option.

I haven’t done an in depth look at the various open source EHR options for a while (I should), but I think the fact that many open source EHR software are now certified EHR and can help physicians show meaningful use and receive EHR incentive money is a good sign. Most of you know that I’m not a big fan of EHR certification, but I do believe that EHR certification takes a certain level of commitment to be able to achieve. Therefore, I think it’s a great sign that the open source EHR options have enough steam and commitment behind them to become certified EHR.

A recent Open Health News post listed the following certified open source EHR:
Ambulatory Open Source EHR
ClearHealth
OpenEMR
Tolven eCHR
Vista (inpatient) Open Source EHR
WorldVistA EHR
OpenVistA
vxVistA
Other (inpatient) Open Source EHR
Indian Health Services’ RPMS

I’d love to hear reviews and experiences that people have working with open source EHR software.

This week, federal policymakers gave providers and hospitals a welcome break in complying with Stage 2 Meaningful Use requirements. The Health IT Policy Committee has voted to delay the implementation of Stage 2 for one year, from 2013 to 2014.

The delay, which is relevant for eligible providers and hospitals that already qualified for MU incentives this year, is a welcome reprieve. Since final rules for Stage 2 aren’t likely to emerge until June 2012, many would have missed their deadlines, something that even the Policy Committee admitted.

Now, the matter of getting Stage 2 rules finalized moves to CMS, which will review the draft recommendations and issue final rules. Nobody’s sure what will happen if the agency doesn’t meet the expected deadline in mid-June, but I guess we’ll just have to wait and see.

In the meantime, as blogger Jim Tate correctly notes, the move raises many questions.

For example, will this decision slow down the implementation of Stage 3 MU rules?  Will eligible providers/hospitals actually take advantage of the delay, or get bogged down and burn through the extra time?  If the eligible providers that qualified in Stage 1 stay there for three years will they only get two years of incentives based on meeting those rules?

I would add a few other questions as well:

* Will those providers who qualified for Stage 1 incentives find adopting Stage 2 to be a reasonable, incremental change or a big leap? Is even an extra year enough to make the needed HIT and process changes necessary to meet this goal?

* Over the next two years, will some providers find that it will cost more to meet the added requirements than they’re getting from the government?

* Will the Policy Committee and other federal officials be able to sell Meaningful Use to newly-arriving providers for 2012, or will there be a revolt of some kind?

I suppose you can see from my questions that a) I suspect hospitals and providers would be unlikely to adopt MU-type features on their own and b) that I don’t know if the government’s existing carrot-and-stick approach can keep  them interested.

Honestly, I’ve always been skeptical that a template-like approach like the MU regs is likely to produce the kind of rich data and improvements in care quality that backers hope. I believe there are better ways to foster smart use of the EHRs the government has demanded.

After all, if requiring certain process changes worked seamlessly, they’d work even without digital medicine, and the whole MU issue would be moot. (The EHR system would support those super-cool care processes rather than being replete with specific features set up as proxies for quality care.)

But maybe I’m being a Luddite or a troglodyte or whomever you are when you’re skeptical that something new works. What do you think?

Carl Bergman, from EHRSelector.com, sent me the following email which poses some interesting questions about various certified EHR vendors and the software that they depend on to be certified.

Many of the [certified EHR] products relied on several other software companies to function. Usually this was Dr. First’s Rocopia, Surescripts, etc. However, many others had required several subsidiary modules to work. For example, Pearl EMR lists: MS .NET Framework 3.5 Cryptographic Service Provider; SureScripts; BCA Lab Interface; Oracle TDE.

There is nothing inherently wrong with this, but it raises three questions. Does the vendor include the price, if any, for subsidiary software? More importantly, how well integrated are these programs integrated into the main program? Does the vendor take responsibility if the subsidiary software changes making them incompatible?

He definitely asks some interesting questions. I’d say that in most cases, there will be little issues with the dependent software. Any changes by the dependent software are going to have to be dealt with or in some cases replaced by the EMR vendor. That will just be part of the EMR upgrade process that the EMR vendor does for you.

The only exception might be things like the third party ePrescribing software. Depending on how this is integrated it could be an issue. In most cases, integration with the ePrescribing software can be very much like an interface with a PMS system or even a lab interface. If you’ve had the (begin sarcasm) fun (end sarcasm) of dealing with these types of interfaces you know how it can be problematic and often a pain to manage. I believe the interface with an ePrescribing module is less problematic, but it will exhibit similar issues depending on how the EMR software works with the ePrescribing.

Personally, I don’t have much problem with these types of integrations. As long as the EMR vendor is providing all of the software for you. The reason this is important is because if you get the EMR software from one vendor and the ePrescribing software from another vendor and then tell them to work together, you’re just asking for a lot of finger pointing. However, if your EMR software chooses to integrate a third party software to flesh out the certified EMR requirements and provides you all of the software, then you’re in a much better position. As they say, then you only have one neck to ring if something goes wrong. You don’t want to have to call both vendors and have each vendor point the finger at the other. That’s a position that no one enjoys.

According to an estimate I heard recently, if a doctor’s productivity drops as little as 3 percent to 5 percent the first year after installing an EMR, they’ve already lost more than the $40,000 they can make from Meaningful Use incentives.  And while there will be exceptions, I can’t help but think that most practices will fall into that category.

After all, EMRs aren’t just new software. They represent a new way of thinking about workflow and the practice of medicine generally.  While that may ultimately be a good thing, over the short term it’s likely that even tech-friendly doctors will need some time to adjust.

So, why are medical practices worked up over MU compliance? Certainly, it doesn’t hurt to stay on CMS’s good side, and the $40K sounds sweet at the outset. Also, I’m sure some practices genuinely believe that EMRs can improve the quality of care they provide — and see the incentives as an added benefit.

That being said, I’d argue that the hunger for Meaningful Use incentives puts far too much pressure on doctors, pushing them to make EMR buying decisions before they’re prepared.  Choosing a piece of enterprise software is tough enough even in hospitals with veteran IT teams in place; for smaller practices, which may not have even a single tech on staff, it’s even riskier.

If I ruled the world (OK, even HHS), I’d spend more on bringing vendor selection, training and change management support to doctors, and focus less on payoffs. But as things stand, CMS seems largely focused on handing out the cash. All I can do is encourage doctors not to be blinded by short-term gain, and phase in EMRs at their own pace.  For most practices, I’d argue, that will work much better over the long run.

When you read this statement from HIT vendor Orion Health, it sounds oh-so-simple: why not establish an entire county’s HIE network on a single connecting platform?  Given the country’s already high EMR adoption rate — about 80 percent of GPs had one, as of March 2010 — New Zealand’s already part-way there.  Just knit offices up together and you’re ready to go.

Orion, of course has its own technology in mind, naturally. But whatever vendor you use, they may be onto something. I’ll pause here to say that the following proposal could incite a riot at a HIMSS floor full of competing vendors, but hey, ideas are harmless, aren’t they?

What if CMS decided that it would pay incentives not just to meaningfully, sensitively, insightfully install EMRs, but to connect them to an overall HIE?  And to take the thought into more controversial territory, what if it had a vendor or two of choice which doctors and hospitals had to use if they wanted the dough?

As we all know, the value of EMR installations isn’t just in automating, error checking and (hopefully) streamlining workflow in practices. The data is infinitely more valuable when it can be aggregated, shared, cross-checked and mined for best practices.

What are the odds of that, however, if you have an outbreak of regional and state projects using technology from a multitude of vendors?  You can talk standards all you want, but true interoperability isn’t going to happen anytime soon this way.  National connectivity?  Well, give me a couple of decades and let’s see how far that’s gotten.

On the other hand,  if CMS signed contracts with HIE technology vendors, and demanded that they give preferred pricing to those work with them, you’d see a rash of connectivity unrivaled since the invention of the telephone.  Before you scream that this just isn’t fair, doesn’t this kind of thing happen every day in, say, military contracting?

I know, I know, this may not be practical. But you can’t argue that It’d be interesting to see how the HIE and EMR market gelled if CMS took a strong lead.

John’s Note: Much of this post will be child’s play for those of you reading the blog that are steeped in meaningful use, the HITECH act, EHR Certification, and the EHR stimulus money. However, I thought this guest post was a nice intro to the EHR stimulus money for a doctor or practice manager which was starting to learn. I’m all about helping doctors, so here it is.

90 days of data collection. This is what is required for year one meaningful use. This means by October 1 you better be collecting data…and hopefully you didn’t just start on October 1…that would be playing with fire.

What really is the purpose of Meaningful Use? In the grand scheme of things, the CMS wants to make sure that a practice hasn’t bundled together a spreadsheet and word processor, call it an EHR, and then try to claim a big reimbursement. So, sure, it makes sense that the CMS would have some requirements for your EHR.

As is the situation anytime you try and get money from the government, the list of requirements is lengthy, the red tape is plentiful and the maze continues to get more complex.

So is the case when “proving” meaningful use. Hopefully you aren’t of the idea that buying a Meaningful Use certified EHR makes you a Meaningful User.

Having an EHR with that “certification” stamped on the box is not like an Easy Button.

Selecting that EHR is the first big hurdle you have to conquer…now you have to show you are a Meaningful User.

The items of proof are shown here in this CMS summary [PDF]. What you’ll see is there are 15 Core Objectives you must be able to report on.

That shiny new EHR should have all of these reports built right in. You better try pulling some of those reports to make sure there is some data in them.

So, those 15 mandatory Core Objectives are already selected for you. Next, there are five more you must select from a gallery of ten.

Which objectives should you choose? Wait for it…IT DEPENDS.

Such the non-answer answer.

It does depend on a number of items, but really which five would you choose?

The easiest to gather? DING DING!

Why not?

Why make this craziness any more difficult than it needs to be.

We’ll go over the Menu Set Objectives, and which ones are the easiest for you to pull, in a future article.

John Brewer is the founder of HIPAAaudit.com. He and his team help physicians run HIPAA Compliant practices in the simplest, most pain free way.

Many of you will probably remember my post about Jim Tate and all his EHR certification experience. As I said in that post, Jim Tate knows his stuff when it comes to the EHR certification bodies (ONC-ATCB). So, I found his advice for EHR vendors on HITECH Answers pretty interesting when it comes to selecting which ONC-ATCB an EHR company should use.

You can go read the whole article, or here’s the Cliff notes version: Responsiveness and Support of the EHR certifying body is most important.

For those who haven’t been following the story of Extormity, a fictional EMR parodying the sprawling, difficult-to-integrate EMRs used by large enterprises, you’ve missed a treat.

Extormity, whose tagline is “Expensive, Exasperating, Exhausting,” proudly boasts that it was accredited by standards body SEEDIE, the Society for Exorbitantly Expensive and Difficult to Implement EHRs.  The company, they’ll have you know, chose its name because its products are at “the confluence of extortion and conformity.”

For quite a long time — as I recall, at least two years — the people behind this sophisticated mockery of big, pompous EMR players have written reams of extremely funny, but telling, material worth of The Onion or The Daily Show for their Web site.

They also churned out a laugh-out-loud series of fake press releases which helped to build their loyal following. (I think my favorites were “Posting as Guam, Extormity Snags ARRA HIE Grant,” and “SEEDIE Announces ARRA Acronym Certification Program.”)

Though the parody got quite a lot of attention, the companies behind it refused to reveal their identities throughout the entire charade.

Now, in a release premiered at HIMSS (of course), the anonymous players have identified themselves (Check out how EMR and HIPAA broke the Extormity news before the press conference):  they’re NoMoreClipboard.com and MIE- Medical Informatics Engineering.

Of course, when the two companies issued a real press release unveiling their true identities, they did some selling, making comparisons between the ponderous Extormity and their real, lightweight, Web-based product. But hey, after years of entertainment, I was very ready to listen.

I take my hat off to the creative, hugely funny people behind Extormity and SEEDIE, and encourage them to continue with their barbed critique of clumsy EHRs.  Hopefully, encouraged by their advice, no one will have to call their new “EHR Depression Hotline.” But you never know…

Today, the most interesting thing I heard in the hallway of HIMSS was about ONC and the government’s perspective on the current EHR certification and meaningful use stage 1.

Someone I spoke told me that ONC is vry focused on getting all EHR software certified. It won’t quite be a basic rubber stamp, but ONC-ATCB’s are to work with the EHR vendors to help as many EHR vendors be certified as possible.

Similar to that, ONC wants doctors to easily be able to show meaningful use stage 1. Then, they’ll tighten down on future stages.

On face, this might not seem like a big deal. No doubt, ONC wants as many certified EHR vendors and doctors that are meaningful users as possible.

However, I find it interesting to think that they’re deliberately trying to get as many people as possible meaningfully using a certified EHR even if those users and EHR vendors aren’t likely to be able to comply with future more stringent requirements.

Will this mean we’ll have a whole wave of EHR users having to switch EHR software once the more stringent standards are implemented? Or will doctors just take the meaningful use stage 1 EHR incentive money and then not worry about the rest of the government handout?

I’m not sure the outcome, but it’s definitely something worth thinking about.

I’ve had a number of EMR companies ask me where they can get help to become a certified EHR. There’s certainly plenty of resources online, but I find that most EMR companies want some real hands on experience and help to be able to navigate the EHR certification process. Whenever I’m asked this question, I always tell those people to go and talk with Jim Tate.

I still remember when I first met Jim Tate at HIMSS last year. I was hanging around the HIMSS exhibit floor because I was early to a meeting with a vendor. I’m sure I was in a partially lost state since I was trying to figure out what to do with the few minutes I had available before my meeting when I heard someone say my name.

I looked up from my lost state to see who was saying my name and saw an all too familiar face for which I couldn’t place. The person then said, “You’re techguy right?” (I’m @techguy on Twitter, and @ehrandhit as well). Then, everything clicked and I said, “You’re Jim Tate right?” See the funny thing was that Jim and I had never met in person, but obviously both of us had seen each others healthcare IT tweets many times before (I think he enjoyed reading my rips on CCHIT pre-HITECH). It’s always interesting (and usually fun) to meet someone in person that you feel like you already know online.

Personal stories aside, I’ve still gotten to know Jim Tate more online than I did in person. I hope that will change at HIMSS this year. Even if it’s just running across Jim on the HIMSS exhibit floor or one of the various parties. Jim has an incredible amount of knowledge and experience in EMR certification. I’m not sure what it says about me that I find the idea of sitting around with Jim listening to old EMR certification “war stories” to be really interesting.

Of course, what prompted my storytelling about Jim Tate? A tweet Jim recently sent that said he’d worked with 90+ HIT vendors. He has a great EMR certification page on his website which has over 75 Ambulatory and Inpatient EMR vendors that he’s worked with. That’s A LOT of EMR companies. You can see the image of EMR companies he’s helped at the bottom of this post.

One ONC-ATCB recently told me that many of the EHR companies that come to them are incredibly well informed, others are just missing some of the details and others are just completely lost. I’m quite sure Jim Tate’s EMR companies fall into the first category.

Now Jim Tate is starting to share his expertise even more broadly as he partners with HITECH Answer and their Virtual Extension Center. Seems like meaningful use consulting will be Jim Tate and EMR Advocate’s next step and probably a very good one. Or as Jim said it:

Time 2 put my shoulder 2 the #Meaningfuluse wheel: http://twurl.nl/it22nb free for EPs, EHs , medical soc, RECs #HITsm #ONC #EHR #healthit

February 10, 2011 2:24 pm via TweetDeckReplyRetweetFavorite

@jimtate

Jim Tate

Jim also gets my funniest tweet of the year award too. In response to @motorcycle_guy’s tweet about who should replace Dr. Blumenthal as ONC head? Jim replied:

Mubarak needs a job. RT @motorcycle_guy: [MG] Who should replace Dr. Blumenthal as #ONC Head? http://goo.gl/fb/l8fPB

February 4, 2011 10:36 am via TweetDeckReplyRetweetFavorite

@jimtate

Jim Tate