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A recent Information Week article on EHR adoption had the following quote:

“I think the number one driver [of ambulatory EHR adoption] is the change in reimbursement, the fact that it is becoming so complicated to document the process of care to get paid by the government as well as commercial payers,” said Nancy Fabozzi, a senior industry analyst at Frost & Sullivan and the report’s author. “Everybody thinks that fee-for-service is doomed and we have to have a new system of reimbursing physicians for the quality of care instead of the quantity of care because costs are exploding.”

In an interview with InformationWeek, Fabozzi said another reason for the adoption of ambulatory EHRs is that many providers have practice management systems that are old and need to be updated as they move to ICD-10 and HIPAA 5010 requirements.

It won’t be news to most of you that it’s not government incentive that is driving adoption of EHR software. The market forces are much stronger than any sort of stimulus. Although, the retarding forces of an unknown stimulus are starting to wear off and we should see EHR adoption pick up again soon.

The Washington Times recently had an article by Tevi Troy and Dr. Jason D. Fodeman about the EMR Stimulus program which talks about how the program might be counterproductive to its goal. The final paragraphs are an interesting perspective:

Unfortunately, Congress and the administration have decided to prioritize “getting it done” over “getting it right.” Other than being able to bring those signs saying “Project funded by the American Recovery and Reinvestment Act” that pop up across the nation’s highways to our hospitals sooner, there does not appear to be much benefit from this approach.

It will take much more than bombarding hospitals with extra computers and complicated, expensive software for health information technology to attain its true promise. It will require the right computers with the right software with properly trained support staff and physicians who know how to use them. All this takes time to establish and time to work out the kinks.

Unfortunately, for whatever reason, the administration is unwilling to devote the time and would prefer to roll the dice and pick up the pieces later. The administration’s rush to establish an interoperable health information technology network may very well prove counterproductive. It easily could waste money, endanger patients and, possibly, do irreparable harm to the technology’s reputation.

I’ve been preaching some of these things for a while, but it’s interesting that the mainstream media is finally starting to pick up the story.

I’d only caution that we not confuse the EMR stimulus with EMR. EMR is no doubt the future of healthcare IT. It’s just important to consider if EMR stimulus is the right approach to getting people to use as the article says “the right computer with the right software.”

Today, I thought it would be interesting to list the meaningful use final rule comments that I know of and to invite my readers to tell me about other meaningful use final rule commentary that they know about. Just reply in the comments of this post or on the EMR and EHR contact us page and I’ll update this post with all the meaningful use final rule resources we can find.

Full Meaningful Use Final Rule, Press Conference Video and EMR and HIPAA MU Thoughts
Comparing the Preliminary Meaningful Use Rule to the Final Meaningful Use Rule Done by Inga from HISTalk and a great resource.
List of Meaningful Use Webinars – Done by EMR and HIPAA
Everything HITECH Analysis of Meaningful Use
Advice on Addressing Meaningful Use – Good advice from the Healthcare IT guy on not being in a hurry to address meaningful use.
Interview with David Blumenthal About Meaningful Use
Mr. HISTalk and John Glaser Reactions to MU (have to scroll down a bit to see the obligatory meaningful use section)
Meaningful Use and It’s Impact on Physician Productivity
HISTalk Initial Comments and Reactions to MU – Just read the comments on this one.
Summary of Meaningful Use Announcement and Rule
CMS Page on Meaningful Use
Meaningful Use Final Rules Are a Big Deal – Wm. T. Oravecz Take on Meaningful Use Final Rule on HITECH Answers
David Blumenthal’s Thoughts on Meaningful Use
John Halamka’s Summary of Meaningful Use Final Rule Changes
Halamka’s Presentation on the Meaningful Use Final Rule
Summary and Other Meaningful Use Documents – The Summary Chart that’s embedded on this is an interesting one. Too bad it’s partially cut off on my screen.
Summary of the 2 Reginas and Meaningful Use – Matthew Holt talks about the 2 Reginas that spoke about Meaningful Use of an EHR
Chilmark Research Quick Meaningful Use Analysis – An always insightful look at healthcare IT
The Fox Group’s Thoughts on Where to Go from Here

I’m sure that there are plenty more. If you know of some good ones, let me know and I’ll add them to the list.

Today I got an email from HIMSS stating that they’ve launched a “complimentary afilliate membership program for RECs.” Looks like HIMSS wants to be able to influence help these RECs with their resources and perspectives. So far they’ve only signed up 10 regional extension centers to the program. Here’s the list that signed up so you can know if you’re REC has joined up with HIMSS:

• HITArkansas
• Colorado Regional Extension Center
• Illinois Health Information Tech Regional Extension Center
• CHITREC
• HealthBridge
• Massachusetts eHealth Institute
• Wide River Technology Extension Center
• Monroe County Medical Society
• North Texas Regional Extension Center
• Michigan Center for Effective IT Adoption

The good news is that this is only 10 of the 60 or so RECs out there. I can’t blame them. HIMSS conference attendance is expensive and free is much better.

I guess I just have a real mixed feeling about HIMSS. As a self proclaimed physican advocate myself, I think that HIMSS has too much EMR vendor influence to be a true physician advocate. I think that being physician advocates is key to successful EMR adoption and will be essential to any REC’s success.

For those of you who don’t read many of the comments on here and EMR and HIPAA, you’re really missing out. Some of the very best discussion and information comes out in the comments. At times I like to highlight some of the more interesting and thoughtful comments so that more people get to read them. This post is one of those comments where a doctor discusses the features that he believes should be included in an EMR that’s built for “Practical Use” as opposed to the meaningless “Meaningful Use.” I don’t agree with a number of his thoughts, but it does give you plenty to think about. I’m sure you’ll enjoy it!

Most of the charts look like:

Patient c/o cough.
HTN -controlled
DM – controlled
CHF – stable
No change in meds.

Those 5 short lines of text are the culmination of a clinical encounter and represent the result of a highly trained professional’s observations, conclusions and treatment plan. With the inclusion of patient name and date of service those 5 lines are the “Complete Medical Record” of that encounter. When Medicare or any other payer shows up to run a chart audit that’s all they want to see. There are certainly other documents like lab results that clinicians use in diagnosis and formulating a treatment plan, but those are simply part of the data “considered” by a clinician and are typically used once. That along with the more signifigant cognative data are processed through the clinician’s brain with the end result being output represented by those 5 lines of text.

When EMR products are designed around that work process EMR ubiquity is possible.

“Meaningful Use” is “meaningless” to clinicians.

“Practical Use” is easy to define, just ask a bunch of doctors who are resistant to the current generation of EMRs. What capabilities should an EMR contain at a minimum that would make it a “I’ve got to have that” clinical tool.

Here’s my list:

1. Must contain a textual clinical note.
2. Must contain a contextual/collaborative problem list.
3. Must contain a contextual/collaborative medication list.
4. Must allow access across enterprise boundaries.
5. Must not interfere with my existing documentation methodology.
6. Training should take no more than a coffee break.
7. Cost must be trivial like my cell phone service
8. Must not interfere with billing and administrative staff’s activities.

I already know how to write a clinical note.
I have finely honed cognative skills, don’t distract me from using them.
I already have a practice management and billing system.
I already get lab results electronically.
I already have e-prescribing.
I am not interested in drawing stupid little pictures on a screen with a mouse.

Finally an EMR must create a secure open channel of communication between clinicians.

I not going to spend $2,000 much less $100,000 to organize and share that information.

Doctors are not Technology Averse, they are Stupidity Averse.

There’s been a whole lot of discussion going on in this post on EMR and HIPAA called Why EMR Efforts Are Proceeding Slowly. The comments are an interesting read for those interested in EMR adoption. However, Jack Callahan, Executive Vice President at SRSsoft, emailed me a very passionate response to that post. I couldn’t let a passionate response like that go relatively unseen in my email inbox, so here’s his response (published with permission):

A major reason why the rate of EMR adoption is so slow is that, despite vendor claims, the actual needs and priorities of the busy, practicing provider are not built in. I’ve worked closely with three EMR companies, and am aware of more than three hundred EMR products, almost all of which, like lemmings, have decided to follow the old CCHIT design-and-development pathway over the cliff. For them, the basic design criterion involves answering the question: “How can our EMR product more effectively generate an automatic Progress Note so the doctor doesn’t have to dictate it, thereby generating cost savings to pay for the EMR?”The answer to that question always seems to be: “Enter a boatload of data from each exam.” Since most of this is entered by the provider him or herself, this is very impractical, especially for busy providers with limited panels to see patients due to surgical or other procedures that generate their primary revenue. The current products pursuing certification have enormous amounts of irrelevant functionality, require way too much data entry, and are largely unusable, especially by specialists and surgeons.

To make an analogy, the current requirements and “certification” process basically dictate that an EMR should be like this:

It should have wings so it can fly, but be shaped like a dump truck because it has to carry a lot of data. It needs to have a half-track undercarriage to provide good traction, no matter the terrain, but it must also function like a submarine in case it ends up in water; further, it must be made totally of recycled, renewable-resource materials for environmental concerns. It must be able to dig deep holes, but also be able to hover; it must be capable of high speeds, but also of changing direction easily. Of course, it should seamlessly switch from any of these modes of operation to any other mode on the fly and without unreasonable delay. Further, it must be adaptable enough to be modified to whatever purpose each user wants, but without giving up a single one of the attributes above, just in case.

Providers must purchase the product with their own funds . . . but may qualify for ARRA reimbursements if they meet certain requirements. These requirements will not be clearly spelled out in advance, however, but will become increasing complex over the five-year reimbursement period, which will end up covering only a small portion of the cost of the product. To qualify for reimbursement, providers must show “Meaningful Use” of the product in their practice—i.e., they must show they can hover, dig holes, navigate underwater, cross a swamp, carry twelve tons of cargo, fly from point A to point B, and spit wooden nickels if requested . . . all without making any mistakes. These requirements will remain in effect even if the practice only needs a simple product that goes in circles around a track.

Any vendor will be allowed to produce these products, but all products will be subject to “certification” that proves they can do all of the above, and more. Every vendor’s product must to be able to exchange parts with every other vendor’s product . . . and with any government-designated agency as well; however, the parts to be exchanged are not specified at the time the product is made. There is no standard for how complex these devices will be to operate . . . vendors will differentiate their offerings by hiring trained users to demo for providers how easy to use their product is by performing “canned,” simple maneuvers that they have spent months, or years, demoing in the past. Vendors can also “guarantee” they have passed “certification” to providers, who may assume that this means that Meaningful Use is also guaranteed; however, vendors have no accountability for Meaningful Use, only for certification. That chicken will come home to roost in 2011.

Some providers see this conundrum more clearly than others. Those are the ones resisting the enthusiastic adoption of EMRs for reasons of incentives alone. But with the marketing and PR weight of more than three hundred vendors seeking certification, with $36 billion in incentives dangling from the government Giving Tree, with the threat of potential penalties for not buying one of the monstrosities above by 2015, and with the offices of ONC and HHS pushing for adoption under administration pressure, how many bad decisions are going to be made in the coming year?

Providers will do best to not use the ARRA incentives as a criterion for adopting an EMR. They should buy an EMR because it makes sense to improve their practice . . . and they should find one that truly fits the way they practice medicine. Meaningful Use should not mean hours of entering data into a menu-driven system. Converting from paper to electronic records provides probably 70% of the benefit of adopting the right EMR, and every single practice will benefit greatly from that alone. Anything else is gravy. And there is lots of gravy to be had, with the right choice. Unfortunately, a bad choice can leave you with a very expensive, unusable, “certified” monstrosity. There are lots of them already lining the roads along the EMR highway, especially where specialists are. And there will be many more starting in 2011 if practices don’t do their homework.

I’m out of town now at a leadership retreat. So, I decided I’d pose a question and hopefully a number of people will leave comments with their thoughts on the subject. Now for the question:

What type of impact will the most recently passed “healthcare reform” bill have on EMR adoption and use?

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.”