Welcome to EMR and EHR

HISTalk had this insightful point:

From Day Tripper: “Re: ambulatory EMR vendors. I asked several EMR vendors if they have seen a big increase in buyers, especially now that we at least have the interim final use definitions. The general consensus is that many physicians are still dragging their feet.” I’ve heard that comment as well. Either because of fear or because it sounds like a good excuse, many physicians are waiting until the MU guidelines are truly final and the certifying entities are identified. Perhaps a minority of physicians are savvy to understand that the RECs will offer some free implementation services so they are waiting for those to ramp up. And, likely others are waiting to see what opportunities their hospitals may offer to affiliated physicians. In other words, if you are looking for an excuse to not move forward, there are plenty to choose from.

I ask a number of EMR vendors the same question. A few had seen some increase, but for the most part they were all still waiting. I think Inga’s comment that there being plenty of excuses to not implement is true. This is unfortunate, since before the EMR stimulus most of the excuses had played themselves out and nearly disappeared. It seems that the EMR stimulus offered up a new set.

I will say that I’m not so sure how much “free” help the RECs will end up giving. I really wonder what most of them are going to do. One of my projects since HIMSS is to make contact with a number of the RECs.

One of my readers sent me an interesting comment about Physician interest in the EMR stimulus:

Personally, I was under the impression that most physicians really didn’t take the time to read such things [like this post about harmful consequences of the Government's EHR stimulus]…that they’d rather be thumbing through Golfer’s Digest or Conde Nast’s Traveler. It’s become quite clear that, when something comes along such as a government program like this that can affect their bottom-line, ears perk up and attention is paid. Now, if only more would speak up and voice their opinions to HHS…

I’ve started to see a bit of a turn myself on this site and EMR and HIPAA by physicians who aren’t too happy with the EMR stimulus. They’re starting to voice their concerns more and more. Some of them are a bit uninformed. For example, they want a “cost effective product that works” and then they ask why the VA system can’t be expanded for civilian use. I’ve talked a lot before about why the VA system has challenges, especially in ambulatory EMR. However, by starting the conversation about EMR, they’ll learn things like this.

I have a feeling that the lasting legacy of the EMR stimulus will be the increased awareness and interest in EMR. Maybe the government should never spend the $18 billion of EMR stimulus money since they’ve already gotten the desired effect of increasing interest in EMR. If after this much increased interest doctors still don’t want to implement an EMR, then maybe we shouldn’t pay them [force them] to do it.

I found this about a week ago and found it really really interesting. Here’s the numbers for the EMR behemoth Allscripts per HIT News:

The company [Allscripts] made $15.8 million in net income for the quarter, turning around a $6 million loss for the same period last year. Non-GAAP net income increased 45 percent, from $16.6 million a year ago to $24 million this year.

The sad part is that Allscripts went through a nice round of layoffs last year. I can’t find the number right now, but I remember it was pretty significant. Too bad they had to fire so many people while turning such a large profit. Seems like an opportunistic cut to me. I wonder how well Allscripts support was with all the cuts.

Another quote from the same article:

“We believe that 2010 will be the ‘Year of the EHR’ in which we expect to see significant acceleration in the adoption and utilization of healthcare information technology to improve quality and reduce cost,” said Glen Tullman, Allscripts CEO. “This is a once-in-a-lifetime market opportunity, driven by the American Recovery and Reinvestment Act.”

There’s no doubt that Glen Tullman is salivating over the $18 billion of EMR stimulus money that’s on the table. He probably should be since Allscripts is likely to make a killing off of the stimulus money.

I think all of this is also a very good sign for smaller EMR vendors as well. I expect a number of EMR vendors to scale to 500 or so installs and sell off for a very nice return in the next few years. I guess we’ll see if Glen’s right about this being the “Year of the EHR.”

As if this was a major announcement, but EMR is leading the growth in the healthcare IT market according to a report by Scientia Advisors:

A new report from Scientia Advisors says health IT is the fastest-growing segment of what the Cambridge, Mass., management advisory company calls a $1 trillion global healthcare products marketplace. Health IT currently is growing at an 11 percent annual rate, and solid growth should continue at least through 2013, which would be the third year of the federal EMR stimulus program here in the States, the Scientia report forecasts. In that time frame, health IT will increase its market share by a quarter, to 5 percent of global healthcare products sales from the current 4 percent.

They also predicted that established EMR vendors should benefit the most from increased spending. “Leading players with large installed bases, proven products, and streamlined routes to meaningful use of EHRs are likely to gain share,” Scientia says.

There’s no doubt they’re going to gain major market share. Add in major mergers and acquisitions by the major players and these companies are going to become huge. Can you imagine the support doctors are going to get from these major EMR vendors?

Recent stimulus-induced EHR deals show sooner-than-expected adoption, especially in the hospital sector, according to investment firm Piper Jaffrey.

The second half of 2010 and all of 2011 are likely to show a large number of EHR deals, Piper Jaffrey analyst Sean Wieland wrote in his analysis Friday.

Wieland noted a growing trend of hospitals buying or subsidizing EHRs for physician practices.

“We continue to believe that mega-deals will continue as hospitals seek to capture first-mover advantage and HHS’ finalization of stimulus criteria will act as a catalyst for stand-alone physician/group practices to jump into the deal foray,” he said. -source

I’d be interested to know where Piper Jaffrey got their numbers that support their conclusion that EHR adoption showed better adoption in late 2010. I guess maybe they’re comparing their numbers to what they thought it would be. Maybe they expected adoption to be close to 0 and it was just over that.

I do think that Piper Jaffrey is dead on when they say that EHR deals will see a huge increase in 2010. It’s going to be the season for EHR adoption.

Do you think that the “mega-deals” involving hospitals subsidizing the EHR will be the reason?

People are always interested in learning what the adoption rates for EMR software are in the US. Chilmark recently posted about a Harvard School of Public Health study that was presented at the PHAT conference. This study focused on EMR adoption rates and the reasons that doctors and practice managers have chosen not to adopt an EMR, yet. Here’s a summary of the findings:

Hospital EMR

• 90% of Hospitals have no functional comprehensive EHR
• Mostly large hospitals and teaching hospitals do
• Top Barriers to EMR Adoption: Inadequate capital (73%), maintenance costs (44%) and physician resistance (36%)

Ambulatory EMR

• 83% do not have a functional EHR
• 17% stated they have purchased an EHR, but not implemented
• 26% plan to purchase an EMR in the next 2 years
• Top Barriers to EMR Adoption: lack of capital (67%), finding a system that meets their needs (54%) and uncertainty of ROI (51%)

The people over at Software advice ran a poll asking essentially whether the HITECH act had created EMR buyers or just brought out the EMR Tire Kickers. Sadly, only 74 people responded. I wish I would have known about it and I would have promoted the poll so we had a wider audience voting to get a more interesting set of data.

The poll did essentially say that right now it’s brought out the tire kickers. I’ve been talking for a while now about how the HITECH act would actually slow EMR adoption (at least in the short term for sure). This poll basically agrees with that prediction.

The question remains whether those EMR tire kickers will turn into EMR sales. I’d be really interested to see the results of the same poll in say February or March. I think we’re going to see a tremendous increase in EMR purchases at that point in time.

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.

Our next guest post comes from Ryan Ricks of XLEMR. In this post Ryan compares the ARRA EHR stimulus money with Governor Napolitano’s mandate to adopt EMR software in Arizona and the alarming EMR uninstall rate.

The HITECH Stimulus Act is part of President Obama’s plan for full, nation-wide use of EMRs by 2014. The act promotes Electronic Medical Record (EMR) adoption by allocating funds to reimburse physicians for purchasing and using a qualified EMR system. In addition, physicians who fail to adopt an EMR will eventually face Medicare reimbursement penalties. Although the goal is lofty, Obama hopes the act’s carrot and stick approach will encourage physicians to adopt EMRs.

However, a recent report by HealthLeaders-InterStudy indicates that Phoenix, Arizona is experiencing a high rate of Electronic Health Records (EHR) uninstalls. According to the report, the trend is due to training, functionality, or affordability issues. Both top-level hospitals and smaller providers struggle with the financial constraints of purchasing and implementing EHR systems. Arizona rapidly adopted EMR systems due to a 2005 executive order by Governor Janet Napolitano, which required that all healthcare providers install an EHR by 2010.

Does this uninstallation trend provide us a glimpse into the future? Will the U.S. share Arizona’s experience at the national level? Arizona’s executive order is similar to the HITECH stimulus act because both seek to rapidly drive EMR adoption to meet an arbitrary deadline. In both cases, physicians feel pressured to make a very important and potentially very expensive decision. Although EMRs provide many benefits, selecting the wrong system, or rushing the implementation process could lead to many problems. It seems that Arizona physicians are scrambling to remove unusable systems due to poor selection or botched implementations.

This does not necessarily mean the HITECH Act will fail. Rather, it means that physicians need to be careful and not rush into a decision they may regret. EMR system prices can reach $100,000 or more. In contrast, the stimulus act will only pay about $44,000 in reimbursements. Physicians should focus on their needs, not wants or superfluous features, 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.
The uninstallation trend in Arizona is a clear warning. Although well-intentioned, the HITECH Stimulus Act may encourage physicians to rashly purchase a system that will not work well in the long run. Physicians must resist the temptation throw in a system just to qualify for reimbursement payments. Instead, they should take their time to find a simple, user-friendly system that meets their needs. After all, $44,000 sounds like a lot of money, but it will probably not cover the more expensive EMR systems with monthly maintenance fees.

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?