In the past, I’ve written volumes about hospital attempts to lock in doctors by offering them access to a free or deeply-discounted EMR. I haven’t heard much about this strategy of late — either the approach was dropped or it’s gone underground — but it seems that other players are still giving it a shot.

This time, in what seems to be a fairly logical step, Quest Diagnostics has kicked off a program offering medical practices a steep 85 percent discount off of the retail price of its Care360 EMR and practice management bundle.  The announcement follows up on its 2011 regional giveaway program, which Quest says attracted thousands of physicians.

The deal, which reduces the physicians’ out of pocket cost to less than $100 per month,  also includes training, hosting, maintenance and 24/7 support for Care360. The lab giant says physicians can get Care360 up and running in about 45 days.

I can’t think of a reason why this wouldn’t make great sense for Quest; if my contacts are to be believed, it has no better reputation than its key competitors when it comes to customer service and follow-through on clinical testing.

On the other hand, if I were a doctor I’d think long and hard before agreeing to a deal like this, even though the software is just about free. There’s simply too much at stake to plunge in.

Yes, Care360 is CCHIT certified and, intriguingly, has incorporated the Direct Project specs allowing doctors to share information with patients and hospitals. And yes, it seems to have made efforts to support EMR access via mobile devices. This is all good. And of course, the price is right.

On the other hand, I’m not sure I’d want to make this big of a commitment to any particular service provider, be it a reference lab, a radiology provider or the people who stock my vending machines with sodas.

I’d argue that the more important the service is, the less you want to be beholden to the vendor. After all,what if Care360 isn’t your cup of tea?  Do you really want to disrupt your relationship with a critical provider like Quest?

Not only that, it’s risky to lock in an EMR just because it’s cheap. If Care360 takes 45 days to get installed, it’s not going to be possible to uninstall it in a day or two, and that could mean misery on wheels if the product doesn’t work for you.

Besides, it’s possible to get Web-based, easy to adopt or drop EMRs for only a couple hundred dollars a month more. It wouldn’t make sense to go for an EMR that might not work just to save that little. (If your margin is tight enough that a savings of $200 or $300 a month is critical, you have worse problems than finding the right EMR!)

I guess I’m saying that even if the EMR is nearly free, caveat emptor. You don’t want to get saddled with an albatross system just because the price was right.

While there’s a number of  large, publicly-traded EMR vendors out there — General Electric (NASDAQ: GE) and Cerner (NASDAQ: CERN) immediately come to mind — to date we haven’t seen many mid-sized or small companies kick off an initial public offering. But one medium-sized EMR/practice management vendor has broken the mold.

Today, Greenway Medical Technologies (NASDAQ: GWAY) took the plunge , pulling in $67 million to fund its operations. While the company had hoped to raise $100 million, its take is nothing to sneeze at. Health IT is a tricky investment, even for pros like yourselves, readers, and institutional investors in particular are a conservative bunch. The fact that they’re spending on a risky business means a lot.

Greenway, whose EMR is bundled with practice management software, had one heck of a ride today, with its stock climbing 30 percent during its first day of trading. The company sold 6.7 million shares at prices below its expected $11 to $13 range, diluting its intake somewhat, but the stock closed at a promising $13 per share.

The Carrollton, Ga.-based vendor has certainly done well in recent times. According to insider Wall Street blog Seeking Alpha, Greenway revenues shot up 55 percent, to $25.7 million, during the last quarter of operations. Operating margins went from negative to a positive 2 percent, which is at least a start.  Its biggest cash generator during the quarter was licensing revenue, which climbed 49 percent.

What’s interesting about this IPO isn’t just the fact that it ended well for Greenway. After all, it did take in less than planned, and the Wall Street crowd justifiably wonders how it will fare in a mind-boggling competitive market.  But it’s worth asking whether Greenway did better because it bundles both an EMR and practice management tools. Did the fact that Greenway wasn’t relying solely on EMR revenue contribute to its growth and financial success?  It would be interesting to find out, as that might help predict whether the bundled model is especially popular with physicians.

As for those who’d seek to imitate Greenway, they may have a chance if they move soon. Seeking Alpha editors think HITECH will still pump enough money into the EMR market to make these companies a reasonable investment. And given how many doctors and hospitals are still struggling to put EMRs in place, I have to agree.  In fact, given that an amazing number of hospitals and medical practices junk their first EMR, there may be a whole second wave of opportunity within three to five years.

All told, if the market’s response to a smallish IPO is any indication, you can expect a bunch of other EMR players to follow in its footsteps.  I’m thinking it will be companies in the $100m to $200m range, as they’re small enough to need capital (much cheaper capital than banks offer these days!) and nimble enough to benefit from the cash influx. Stay tuned and in coming months, I’ll tell you which other EMR and HIT companies I’m betting will climb onto the launch pad.

Here’s an EMR adoption study which interested me largely because it runs counter to what I would have predicted.  The study, which surveyed physicians pre- and post- EMR implementation, found that doctors who owned a stake in their practice found their rollout to be tougher than physicians who didn’t have a stake.

I don’t know about you, but I would have assumed that the folks with more control — the owners — would have found it easier than those who have to adapt to the decisions others make.  But it seems that physician-owners simply feel the pain of change more acutely.

To conduct the study, which was published last week in the Journal of the American Medical Informatics Association,  researchers surveyed 156 physicians working with the Massachusetts eHealth Collaborative.  The surveys included a pre-implementation questionnaire  in 2005 and a post-implementation questionnaire in 2009.

Thirty-five percent of doctors who responded reported that implementation was very difficult, 54 percent said it was somewhat difficult and 12 percent not difficult. Those numbers square pretty well with what I’ve seen elsewhere. The twist here was that 38 percent of physicians with full or partial ownership stakes in their practices voted “very difficult,” versus 27 percent of non-owners. That surprised me. After all, aren’t most of the complaints coming from doctors who try to use the new systems?

According to Marshall Fleurant, MD, one of the study’s authors, the owners “probably experienced more underlying challenges associated with EHR implementation and workflow transformation” given their broader operational responsibilities.

While this study is interesting, it’s hardly the last word. Teasing out just which factors predict how doctors will react to EMR implementation, much less what it takes to support them, is still a new science.  But it never hurts to bear in mind that physicians making critical management decisions get support, too.

For quite some time now, I’ve nursed my own doubts about:
- how effective EMRs are (disastrous in the short term, long term they’re supposed to make life easier, but we haven’t seen any evidence of that yet)
- why physicians are being paid to implement something that makes logical sense (you need something to nudge people out of status quo. And probably in the government’s thinking, what better use for taxpayer dollars, right?)

I came upon this blogpost, provocatively titled Why EMR is a four-letter word to most physicians. Adam Sharp, Par8o (“pareto”, not “par 80″) founder references this post from the Healthcare Blog. The discrepancy in the rates between adoption of any EMR is mind-boggling. It was projected to be close to 56.9% in 2010, vs. adoption of a fully functional EMR (projected to be close to 10.1% in 2010). (I’m not using the 2011 rates because the rates for fully functional EMR adoption in 2011 are not listed).

A reason Sharp gives for incentives and threats of decreased payment are “the industry and physicians have known for years that EMRs do not improve productivity and that it is highly questionable that EMRs lead to better patient outcomes”. While I would agree that in the short term, there is decreased productivity, I’m not so sure you can dismiss there is no productivity increase over the long term. This report about a UC Davis study for example, shows that the loss of productivity was just one month for internal medicine, and that productivity increased to pre-EMR implementation levels in the next six months. The not-so-good news is that productivity levels declined for pediatricians and family practices.

I interpret these findings like this: for specialties where there is loss of productivity, sure, the whole exercise needs a rethink. But in cases where your productivity is at par with your pre-EHR levels, I think there is a hidden benefit that detractors are more than willing to gloss over – the availability of patient data. Data is the holy grail – it’s up to us to figure out whether and how we use it.

Sharp also imagines some doomsday scenarios – of EMR vendors with uncanny abilities to do as they please.

“The goal of EMRs is to wrestle control of healthcare away from the doctor-patient relationship into the hands of third parties who can then implement their policies….by simply removing a button or an option in the EMR.”

Maybe I’m turning turncoat here and letting you guys in on the best kept secret of the IT industry, but every vendor I’ve worked for, past and present, figuratively quakes in his IT boots when it comes to contract renewal. Even for COTS products, vendors actually customize things here and there for customers, till you have 25 versions of the same code, all just to keep their customers happy and paying. While I’m pretty sure there are rogue vendors who can give you the best EMR nightmares money can buy, I also do think customers can, and do, help rein in errant ideas. In other words, vendors can’t simply remove buttons and options or randomly start charging you for stuff, not unless you let it happen. And you, the customer, hold the purse strings, ergo YOU, not the vendor, call the shots.

I don’t quite find myself agreeing with the cynical conclusion of the post which is that the point of EMRs is to wrest control away from doctors and patients into the hands of third parties who wish to regulate choice and eligibility. But there’s plenty there that’s food for thought. Go check it out.

In case you missed it, I’ve moved a lot of my discussion of the EMR and Health IT markets to my site: EMR Thoughts. I’ve done a lot of posts on that site that look at the EMR market, the health IT investments, the Health IT incubators (or accelerators if you prefer), and other movement in the EMR, EHR and Health IT markets. If you like that type of content, you should definitely subscribe to the EMR Thoughts email list.

Even though, I’ve moved a lot of my EMR market discussion to the other site, every once in a while I’ll drop in some EMR market stuff on here as well. In the article linked in my Costco EMR post, they discussed the size of the EMR market:

Millennium Research Group said in its November report, “U.S. Markets for Electronic Medical Records 2012,” that the U.S. market for EMRs will exceed $8 billion by 2016, with the fastest-growing segment occurring in the small-practice market. Web-based EMRs that don’t require an expensive information technology infrastructure are contributing to the growth, the report said, because they are an affordable option for small practices on tight budgets.

I always hate when they don’t split the EHR market into ambulatory EHR and hospital EHR. I also still haven’t figure out a good way to reconcile that the EMR market in the US will be $8 billion in 2016, but we’ll have spent a good portion of the $36 billion of EHR stimulus money by 2016. Those two numbers don’t jive very well.

I also find it interesting that the fastest-growing segment of the EMR market is the small-practices. I’m not sure I agree with this. I think the larger sales and hospital EHR sales are brisker than the small practice EMR market. Much of the small practice market is still “waiting and seeing.”

I’ve blogged before about the importance of decreasing the digital divide in this country in order to truly move healthcare interoperability forward. As I mentioned last month, “Only those patients who have access to these digital healthcare technologies will begin to clamor for them at their next doctors’ visits. Only patients’ whose doctors in turn have reached out to them via email, text or social media regarding the switch to electronic medical records, development of health information exchange and the benefits to care these will hopefully bring will be ready and willing to go with the digital flow.”

When news came across my somewhat cluttered desk of Emdeon’s initiative to provide electronic health record (EHR) technology to physicians in New Jersey’s underserved communities, I first thought, “Yes! That’s what I’m talkin’ about!” Then I put on my journalist/blogger hat and thought, “Will this truly change anything in these particular communities, or is this just good PR?”

A quick bit of background: Emdeon is partnering with the U.S. Department of Health and Human Services’ (HHS) Office of Minority Health, New Jersey Health Information Technology Extension Center (NJ-HITEC), the state’s REC, and the HIMSS Latino Community. Through the initiative, Emdeon will donate Emdeon Clinician licenses to 100 healthcare providers who practice within medically underserved areas and/or healthcare provider shortage areas, as designated by the Health Resources and Services Administration (HRSA), according to a recent Emdeon press release. The company will waive the license fee for these physicians for one year.

The same press release also mentions “EHR adoption is lower among providers serving Hispanic patients who are uninsured or rely on Medicaid, and is lower among providers serving uninsured, non-Hispanic black patients than among providers serving privately insured, non-Hispanic white patients.”

The initiative sounds like a great idea, but the one-year stipulation got me thinking (a bad habit, I know). What will these physicians, who presumably can’t really afford this technology now, do after their year is up? I reached out to Miriam Paramore, Senior Vice President – clinical and government services at Emdeon, to learn more about the ins and outs of the program.

How did the initiative come about?
Miriam Paramore: During the fall of 2010, leaders from the Office of Minority Health (OMH) and Health Information Technology issued a public, written request to health IT vendors, asking them to pay special attention to healthcare providers within underserved communities. This initiative is known as The Alliance to Reduce Health IT Disparities. Emdeon is serving as a private partner with the OMH to offer access to health IT products and services to providers within undeserved communities in New Jersey. We were thrilled to volunteer and to work within these communities.

Has Emdeon ever done anything like this before?
We’re happy to do part of this effort with HHS and it is the first time we’ve partnered with them.  We have great empathy for the challenges of the physicians in underserved communities and we want to help.

What sort of challenges do small physician practices in underserved communities typically encounter?
In addition to challenges like poverty and health disparities amongst their patient population, providers in underserved communities and smaller practice offices face expensive costs associated with on-boarding EHRs. Emdeon created the Emdeon Clinician solution as an affordable EHR “lite” solution for these small practice physicians or those working in underserved communities. They now have an affordable, easy-to-use solution that will help them to qualify for federal HITECH stimulus dollars without unnecessary disruption and expense of a full-blown EHR system.

How will you work with these 100 physician practices to ensure they are able to continue using the donated EHR after the year-long license expires?
Once the 12-month period expires, providers will be able to continue using Emdeon Clinician for only $99 per provider, per month. Emdeon usually has a $500 implementation and training fee [that, for this program,] has been discounted to a one-time fee of $200 for the providers participating in this project. This is a considerable discount and the fee would only have to be paid once. We will begin outreach to these providers in advance of the expiration date so they are aware of the opportunity to remain with Emdeon Clinician for the low fee following the initial 12-month period.

How will Emdeon work with NJ-HITEC and the HIMSS Latino Community throughout this year to ensure that these practices receive continued training and support?
Emdeon has taken the lead with managing this initiative between all partners with monthly meetings to monitor progress. We have a dedicated project manager, who has mapped a process with the internal team to assist with implementing these physicians as soon as possible. Our custom phone number (1-855-840-7120) connects interested providers directly with a dedicated clinical sales executive who can assist them throughout the enrollment process.

The NJ-HITEC and HIMSS Latino partners are assisting in the recruitment of providers who practice within medically underserved areas for this program from their vast networks across New Jersey communities. These partners are working cooperatively with Emdeon to create a strategy that focuses upon identifying and recruiting providers within underserved communities who are willing to adopt EHRs, especially those interested in qualifying for federal incentive dollars.

How many practices do you anticipate being eligible, and how many do you expect will apply?
While we aren’t sure how many will apply, the HHS OMH recognized that the counties of Camden, Essex and Passaic have the largest percentage of underserved communities. Through our collaborative efforts with the OMH, HIMSS Latino and NJ HITEC, we hope to reach many of those physicians within those counties to take advantage of the 12-month program.

How will Emdeon and its partners determine if this program is a success?
Together with our partners, we believe success will be donating all 100 licenses to providers in underserved communities. The reporting element of this project will help OMH understand the progress of EHR adoption in the context of how long implementation takes in its entirety.

So it seems that Emdeon and its partners certainly have their ducks in a row when it comes to aiding and abetting these physicians before, during and even after the program is technically over. I’ll be interested to see if this model will, in fact, be successful, and if it can be supported in other underserved areas across the nation.

For more information on participating in the program, check out: http://www.emdeon.com/newjersey/

Not long ago, I recently posted an item on HospitalEMRandEHR.com discussing how one hospital dropped plans to distribute iPads as front-ends for its Cerner EMR.  Doctors at hospital, Seattle Children’s, gave the iPad very bad reviews as an EMR-connected device, in part because they felt that Cerner’s system was too hard to use via a Safari browser.

Since then, a few readers have commented on the story, and interestingly, they’ve offered more nuanced feedback on what works (and doesn’t) in deploying a tablet as an EMR device for clinical use, including the following:

* Deploying the iPad initially offers a patient “wow factor” — in other words, it may make providers look hip and up-to-date technically — but that doesn’t last very long.

* Even a well-designed, tablet-native tablet app may still be frustrating for clinicians to use, given the high volume of information they need to enter. (Paging through a dozen screens is no fun.)

* When choosing a tablet, be aware that the physical performance of the tablet (especially the touch screen) can be a big issue.  If clinicians “touch” and the screen doesn’t respond, it can throw them off their stride.

It’s hard to argue that hospitals (and medical practices) should take mobile access to EMRs seriously. And anyone here would know, most organizations are.  After all, now that health IT industry is looking hard at mHealth, smart new ways to use mobile devices in care seem to be springing up daily.

But before you dig too deeply into your mobile strategy, you may want to hear more clinicians on how their mobile EMR usage is playing out. Call me a curmudgeon, but it seems to me that it may still be too early to invest big bucks in a tablet for mobilizing your EMR just yet.

Don’t get me wrong: I’m convinced that someday, every doctor will enter and access patient data via some sort of mobile device. But it seems that there’s some fairly important technical issues that still need to work themselves out before we can say “this is how we should do it.”

Earlier this year I had the good fortune (and the support of my employer) to join the Technology Association of Georgia (TAG), an organization that offers interest groups for every possible IT niche you can think of. I’ve attended a few of their health society events, and at every one I’m confronted with statistics and anecdotes surrounding the dearth of qualified healthcare IT professionals in the city and surrounding areas. Much attention at these events is also given to the fact that these professionals are needed now more than ever to help smaller physician practices and larger healthcare systems demonstrate Meaningful Use and achieve associated electronic medical record (EMR) adoption goals.

I’ve commented before on the disconnect between the increasing number of healthcare IT educational opportunities being created by the government and vendors’ willingness (or unwillingness, as the case may be) to hire fresh grads. EJ Fechenda of HIMSS JobMine posed a question related to this conundrum better than I ever could have: “With federal deadlines looming, healthcare organizations need to get moving and there are a lot of job seekers out there ready for the challenge. Are there organizations or companies willing to extend opportunities to these candidates? Is there a training or job-shadowing program that can be used as a best practice for other organizations to implement? Who are the champions already doing this or willing to lead the charge?”

I may have found a champion in Rich Wicker, HIMS Director at Shore Memorial Hospital in New Jersey. Wicker is also an adjunct professor at two HITECH-affiliated community colleges, teaching students who already have strong backgrounds in healthcare or IT the basics of process, analysis, redesign, installation and ongoing maintenance to prepare them for second careers in physician office EMR implementations.

He certainly seems to have a passion for the subject. “I’m devoted to the EMR,” he told me during a recent phone interview. “That’s why I started teaching, really, because I want to see that [adoption] happen so badly.”

He tells me his students are guardedly optimistic about their future job opportunities, which he believes will surge this summer alongside an expected increase in physician adoption of EMRs – six months before the deadline to qualify for Meaningful Use incentives.

As we discussed the state of the HIT job market, we both wondered if what type of organization might have a greater role to play in ensuring that graduate from programs like Wicker’s find jobs.

“We had to really battle our way to get one [software] copy from one EMR vendor,” he explains. “I wish they were more amenable to providing educational software/packages like Apple does throughout all their PCs. I know a few different schools have joined with a vendor. One place I know of is showing Vista, another is showing eClinicalWorks, and another partnered with a local hospital that happens to use Sage.

“I have a relatively limited view, but from what I can see, the vendors are not really engaged with the HITECH student development program. I think they’d probably rather do it themselves.”

“Here’s an idea that I came up with,” he adds. “I’ll throw out the RECs (Regional Extension Centers). That’s another entity that’s funded – it’s kind of their job to get the docs to convert. If they could partner with the colleges and the graduates to possibly divert some of their funding to supplementing the graduates’ income while they worked at a physician practice … So the physician, let’s say, for $5 an hour, they could hire a qualified, certified person. These people are pretty good, too. They know what it is to work. They’ve probably worked 10 or 20 years already, either in IT or in healthcare. So they’re mature employees and highly motivated. They would be great to go in and do a 6-month installation. I think it would be great for the physician if, for $5 an hour, you get somebody that would probably cost you $30 an hour somewhere else.

“Let’s say the student can get another $10 an hour supplemented from the REC or somehow through the government. So they get $15 an hour to go in there … they get four or five months of experience doing an installation and then the physician can make a decision … maybe they ultimately hire the person. That’s just a crazy idea that I had that seemed like the pieces are out there that kind of potentially could work. I sent it into the ONC a couple of days ago.”

Could the RECs have a bigger role to play in ensuring that HITECH graduates gain on-the-job experience and employment? I’d love to hear from any readers out there who may work for or with RECs . Is Wicker’s idea doable? Have we found our champion?

Note:  The following is not to be taken at face value, exactly — I’m not literally convinced that it’s time for a revolution — but you might see a point or two here that are worth considering further.

Doctors, are you sick of having an EMR pushed down your throat by administrators and IT leaders that don’t care how disruptive or painful the change may be?  Do you feel like your complaints and concerns aren’t being heard?  Are you actually afraid a patient will be hurt someday because of the EMR’s limitations?

Well, I say it’s high time you get radical and OccupyYourEMR!  Get in there and resist until your (absolutely critical) voice is being heard.

If you don’t, you know you’re going to be steamrolled into using a platform that’s awkward, ugly, inflexible and slow — in short, a system only the IT admin and hospital board who funded it could love.   Maybe you’re not ready to stop working, but what if you refused to log in?

As things stand, you have little to gain and a lot to lose by blindly kowtowing to EMR adoption demands.

Hey, if Hospital X installs an EHR and it seems to work, the CIO and the CEO and the board of directors look like geniuses. Some of them will probably get big bonuses if everything falls into place just right.

You, on the other hand, will be lucky if the new system doesn’t cut your work pace in half, confuse you and make charting a painful chore. Oh, and if things really go badly, you’ll harm or kill a patient because you didn’t read the EMR right.  Of course, the hospital will be right there beside you offering the best legal defense money can buy, right? (Uh, not really…)

Yes, there are some stories out there about EMRs that actually improve patient care and make doctors’ lives easier, but let’s face it, there’s a reason we don’t publish a ton of those here (or on sister blog Hospital EMR and EHR).  I’m not suggesting that all EMR rollouts are a mess, but few are a walk in the garden either. And it’s more common than you might think for a provider organization to go through a second or even a third installation before everything works.

Hey, don’t misunderstand me, I still believe EMRs are going to be a positive force over the long term.  In the mean time, though, some clinicians will be casualties — either becoming burned out by new work expectations, hating the new process or even making dangerous mistakes. Don’t be one of them.

Demand an EHR that helps your workflow, helps you provide better patient care, makes your life better, and lives up to the expectations the EMR salesperson made. An EHR that does those things will be welcomed by almost all doctors and other staff.

I’m writing to you from the balmy, breezy and absolutely beautiful Palm Springs, where the Porter Research team presented several sessions at this year’s Healthcare IT Summit. It’s my second year attending this conference, unique in that it brings together providers and payers for joint sessions and networking opportunities. I enjoy it because it’s an intimate setting in which to chat with providers about what their challenges are and how they plan to face them. Something you definitely don’t get at big shows like HIMSS. California is a nice change from last year’s chillier venue of Washington, D.C.

Little did I know that casinos are part of the after-hours culture in Palm Springs. Driving in from the airport – the smallest and prettiest I’ve ever been through – I noticed the bright lights of one of them, which reminded me of an article I came across last week regarding the state of Massachusetts’ plans to use anticipated revenue from casinos to accelerate the adoption of electronic medical records. Apparently, 23% of licensing fees from the state’s three casinos and one slot parlor may potentially go to a fund “designated in part to help the state switch to an electronic medical records-keeping system.”

Massachusetts, which already requires nearly everyone to have state health insurance, is doing what many other states have done in terms of leveraging gambling revenues for government projects. I myself have benefited from Georgia’s HOPE scholarship, which is funded from the state’s lottery.

Will other states follow suit? Is this an example of creative thinking on the part of the state government, or is there something amiss with private citizens spending their money in Native American casinos, which the government then takes a chunk out of for its mandated programs? I’ll admit, I’m a bit torn. Do we rah, rah, rah the out-of-the box thinking, or pooh pooh it because it’s too close to the vest?

Judy Hanover at IDC predicted in one of her sessions at the summit that the majority of US providers will be using electronic medical records by the end of 2012, with large physician practices leading the way. According to the US Bureau of Labor and Statistics, there were 661,400 physicians in 2008, with 805,500 projected to be employed by 2018. Even taking into consideration the predicted shortage of physicians, that’s a big number to totally move from paper to digital in just a few years.

I wonder if we’ll see other creative funding ideas pop up – whether they be from the government, private investors, or even payers. A speaker at the summit brought up the notion of taxing soda to encourage folks to be healthy as part of this nation’s move to more coordinated care and more formal accountable care organizations. Could money from programs like that be used for EMR funding? Let me know what you’ve heard and think in the comments below.