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.

One foggy morning last week, I made my way to the Georgia State Capitol for a Technology Association of Georgia (TAG) Health event relating to the intersection of healthcare IT and state legislation. Little did I know that the state’s government is somewhat unaware of the benefits HIT can bring, both to the patient in terms of more coordinated care and improved quality outcomes, and to the state in terms of job creation and revenue.

I also was not aware that, when it comes to moving from paper to electronic health records, some doctors take a bit more convincing than others. And when I say “a bit,” I really mean they may need to be gently dragged kicking and screaming into the digital age. At least that’s the impression I got at the TAG event after speaking with Sherri Mesquita, an EMR/EHR Consultant – Project Manager, at Community Health Systems Inc. She works with ambulatory clinics and hospitals to help them establish strategy around meeting Meaningful Use deadlines, and has developed a keen sense of when doctors may need an extra “bit” of convincing.

What do you think the biggest challenge is for doctors when it comes to accepting that it’s time to change – to make the move from paper to electronic health records?
I believe the biggest challenge is that in order for them to understand how the EHR experience will be beneficial, you have to get them to actually buy into the idea of an EHR. Doctors want to know that the ROI on their investment is going to bring increased revenue to the practice/hospital, provide more efficiency in the practice, and above all provide the best possible quality of care while keeping costs down.

Physicians talk to other physicians about these newer technologies. If they see their cohorts are doing well, and consistently discuss the positive attributes of the EHR software, other physicians are more likely to follow them in adoption – depending on how much money, time and staff resources are currently available.

In addition, some physicians have already implemented an EHR system in the past and, unfortunately, did not get the right information or customer support, or the vendors were not trained in how and which system works best for that specific clinic. Therefore, those doctors have not had a positive experience in the past, and even went back to using paper after spending thousands of dollars on a system that either was not customizable or did not integrate well with the other practice management or billing programs.

In your experience, when does the light bulb go off in a doctor’s mind – when do they realize that it will truly be to the benefit of their practice, their bottom-line and, ultimately, their patients?
There needs to be a lot of hand holding in the beginning stages, and education is key to them seeing what benefits to the practice an EHR can be. Other doctors again are a very important and vital aspect to implementing an EHR. They bring actual experience and important testimony for the process of going electronic.

Last year, I worked on a program with the Rockdale Chamber of Commerce in Georgia to provide a “transfer of knowledge to doctors” by educating them on the important benefits of implementing an EHR, as well as adopting “Lean” and “Continuous Improvement” in their practices. The purpose of the CI/Lean techniques is to achieve unity of purpose to identify and sustain improvements to patient critical needs.

How do you help them reach this point? What examples do you typically give to show them the value of an EHR?
Though the initial costs and implementation challenges are considerable, delaying implementation today may create additional resource drains tomorrow. The availability of an EHR may soon be a minimum standard for new physicians, public and private payers, and patients.

• EHRs are an essential component of reform-related efforts such as the Patient-Centered Medical Home (PCMH).
• Practices that do not meet Meaningful Use criteria will face Medicare penalties in 2015.
• A certified, operating EHR will be essential to participation in both public and private pay-for-performance programs expected in the future.
• According to the Deloitte Center for Health Solutions, 42 percent of consumers are interested in establishing an online connection to their physicians through a personal health record and 55 percent of consumers want the ability to communicate online with physicians.

Can you give any specific examples of EHR implementation success stories? Or perhaps from the other viewpoint – an example of a doctor or practice that absolutely refused to make the transition, and why?
Most recently, I have worked with ambulatory practices in Toledo, Ohio – Catholic Health Partners. The doctors and nurses fought it every step of the way, and even threatened to leave the practices. It was a very hard adjustment in the beginning, and for me as a consultant to come in and change the workflow processes and implement new software rollouts was such a challenge.

I was able to work one on one with the clinical staff and help them to understand they had someone there to guide them through the entire process. They definitely demonstrated gratitude when they could see the end result after two weeks of being live with the software. The practices needed to make sure they scheduled their patients at a 50-percent reduction rate to accommodate the change in software for the first two weeks.

The practices gradually implemented the EHR software of Epic, which resulted in maintaining positive patient-physician relationships and fostering the sharing of medical information. After demonstrating proficiencies, the physicians and other clinical staff were comfortable with the new EHR systems and even say they could then see the potential benefits of the new changes.

Could a single, mammoth database solve all our health data needs? Margalit Gur-Arie, whose writing and ideas I greatly admire, has been arguing for one quite passionately on her personal blog in a couple of recent posts (part I, part II).

The crux of her posts is this:
- There should be a single, standardized national database to which physician practises, and ultimately EMR vendors, must submit mandatory data, “in real time”. The requirements will be along the lines of current Meaningful Use requirements.
- This database will be accessible to vendors and entrepreneurs alike, and can have multiple EHRs or apps built atop them.
- Since the patient data is available, and easily accessible (no one “owns” the data, they only own the proprietary bells and whistles they perform on the data), this is a near perfect patient utopia.

It’s a great idea and perfect for an ideal world. Except:
- Massive databases cause massive headaches, as commenter Omowizard pointed out. There is a price to pay for data available at all times, all places, and by everyone. And if I may add, in Gur-Arie’s model, it’s not clear who’s left holding the bag. Presumably the government. Which opens a entirely different can of worms about data ownership.
- Real time updates of data is no joke. At my current place of work, we perform quasi-real time (twice daily) updates of patient visits to client databases from a central repository. The sheer volume is enough to bring down the database servers for a good hour or two.
- We haven’t been able to agree on a standardized schema passed for a healthcare database. What are the odds of this idea ever catching on?
- How are we going to mandate data population? After physicians and care organizations, will EMR vendors be the next recipients of government bribes/largesse/sops to induce them to populate the database?
- Gur-Arie herself points out that American enterprise being what it is, if there are no financial benefits to data ownership, they’re going to be a hard sell.

And while it’s easy for me to write a smart alecky blog post about the infeasibility of the mammoth database idea, I shudder when I think of what we have now: disjoint EHRs that don’t “speak” to one another, walled gardens and proprietary ownership of data that pretty much lock physician office in, PHR offerings from companies like Microsoft who will do God knows what with OUR health data.

I don’t think there are any easy answers. I’m leaning more towards an open source health “OS” platform rather than a single database. But at the very least, Gur-Arie offers some great food for thought.

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.

Here is a quick look at some of the other articles recently posted on some of the other HealthcareScene.com websites:

EHR and EMR Videos
Software Demo of ADP AdvancedMD + EMA Ophthalmology
This medical billing and EHR software demo presents how medical practices can use ADP AdvancedMD as their practice management to collect more money, faster. EMA for ophthalmology helps doctors utilize an iPad to manage clinical charting and see more patients faster. A software bridge (data integration) has been built to help staff work faster without doing double data entry.

HIMSS Analytics: Data, Research and Consulting for Healthcare IT

Gain a deeper, more vibrant understanding of the HIT space through HIMSS Analytics. Knowing who needs what, when they need it and who to contact will enable you to sell proactively to receptive customers. Our market intelligence will help you optimize your marketing and sales strategies to advance the future of healthcare.

Steve Hinajosa Explains Advantages of DocBook MD 3.0

Travis County Medical Society Membership Director, Steven Hinojosa explains why local county Medical Societies should be interested in DocBookMD 3.0.

EHR and EMR Screenshots

The links below represent screenshots from the Care360 EHR/EMR including images from the EHR, the iPad app, and the mobile app.  Do you think it is necessary for EHRs to use multiple platforms for access, or is it unnecessary vanity?

Screenshots from the Care360 EHR/EMR

iPad App Screenshots from the Care360 EHR/EMR

Care360 EHR/EMR Mobile App Screenshots

Smart Phone Health Care

Consult A Doctor Offers 24/7 Flu Hotline That Costs Less than $40

Flu season is generally miserable for everyone.  Even if you don’t actually get sick you spend half your time avoiding the people who are sick.  Then you start to get symptoms but you wait as long as humanly possible to actually see a doctor because it is so expensive and time-consuming.  Consult A Doctor is releasing a new service designed to change all of that.

Qualcomm Tricorder X Prize Offering $10 Million Prize to Developers

We all remember those awesome little tricorders from the Star Trek series that could analyze a person’s level of health almost immediately.  All the doctor had to do was push a button and he immediately knew exactly what he needed to do to help the person.

Qualcomm and the X Prize Foundation have announced a development competition designed to create just such a device.  The two CEO’s of the respective companies, Dr. Paul Jacobs, Qualcomm Foundation Chair and Qualcomm Incorporated Chairman and CEO, and X PRIZE Foundation Chairman and CEO Dr. Peter Diamandis, announced during the keynote address at CES that the prize would be $10 million dollars.

I’m sure that some of you might have seen me complaining on Twitter about the challenge of trying to sift through the 300+ educational sessions at HIMSS. I even tried to convince the HIMSS expert Neil Versel to offer up some suggestions on which HIMSS 2012 sessions to attend. He suggested just leaving all of the education times open and decide later. It’s a good idea, but I think I prefer meeting with people more than some of the available sessions. Neil enjoys the sessions a bit more than I do.

One of my favorite old Neil Versel posts was when he basically said, “HIMSS is more than just the exhibit hall.” With 300+ sessions at HIMSS 2012 there should be something you will find interesting, so HIMSS should be more than just the exhibit hall.

Today I started ripping through the HIMSS sessions to try and identify those I found interesting and worth putting on my schedule. While they might make it on the schedule, that doesn’t mean I’ll necessarily attend. I debate attending based on the flow of the conference, people I’m with at the time, and if I’d already heard enough on that subject for one HIMSS. Plus, I often put multiple sessions that are at the same time on my schedule. In those cases, I use the above criteria to decide which ones I should attend.

The other X Factor with this all is that I still have to schedule my meetings with vendors I find interesting during HIMSS as well. I’ll start doing that now that I know which HIMSS sessions are happening when. At least now I won’t schedule a meeting with a vendor during the Biz Stone keynote. That would be a travesty.

Below you’ll find my HIMSS 2012 schedule of sessions (which will likely continue to change), but for those interested here’s the process I did to find interesting sessions. First, I added the exhibit hall hours and keynotes. Next, I went through the HIMSS Specialty Programs and HIMSS Social Media Center schedule (My HIMSS Panel on Wed, 2/24 from 4-5 made it on my schedule from this list). Then, the HIMSS Education section has the sessions broken out into “Core Education” areas. I found the Federal Participation at HIMSS 12, Senior Executive sessions and EHR Best Practices sections quite interesting.

There you have it. I’m sure I missed some sessions I should attend, so if you know of some that you think are worthwhile do let me know and I’ll check them out. Now without further ado, my current schedule for HIMSS 2012:

As you can see it’s going to be a full and crazy week for me at HIMSS 2012, but as I said before HIMSS is great for me. Everyone goes there with a little different plan on what they want to accomplish and learn, but hopefully my list of sessions will be helpful to someone else navigating the HIMSS 2012 gauntlet.

Let me know if you have any questions about particular sessions and I’m happy to tell you why they made the list as well.

Recent news that Kaiser Permanente has made its patients’ electronic health records available via mobile devices comes as no surprise. Kaiser often seems to be at the forefront of interoperability and coordinated care, in large part due to its integrated nature and sheer volume of patients. As the company’s press release mentions, it maintains the “largest electronic medical records system in the world.” Now, 9 million of its patients can view their EHRs via a mobile site or Android app, with an iPhone app expected to launch in the near future.

On a macro level, I think this is a great step towards further empowering patients to take control of their health. By giving 9 million folks instant access to their own health information, I’d like to think that this will in turn prompt their friends and relations to ask, “Why doesn’t my doctor do that? What benefits am I missing out on?” And perhaps these same folks will then have a conversation with their provider about adopting this type of mobile access.

I’d be interested to see six months to a year from now, statistics comparing use of the mobile app/site to use of the tools found on the traditional website. Will Kaiser see a tremendous increase in the amount of emails between doctors and patients via its mobile apps? Are its doctors prepared for the potential onslaught of correspondence? I wonder if a few have balked at the possibility of being overrun by emails from particularly communicative patients.

Will they be able to tie these usage statistics to a jump in quality outcomes? Will mobile access ultimately become a criteria measured within accountable care models or patient-centered medical homes? Will mobile health truly equal better health?

On a micro level, I would certainly appreciate the effectiveness of access like this, which includes the ability to view lab results, diagnostic information, order prescription refills and the aforementioned email access to doctors. I can’t tell you how many times I’ve been on the phone with a pediatric advice nurse and drawn a blank when asked what my child’s current weight might be. It would be nice to be able to quickly pull that data up on my cell phone, especially while we’re on the go or out of town. I could eventually see patient charting apps being layered on top of this, so that in the event of a high, overnight fever, I could log temperatures via the mobile app and review them with our pediatrician – possibly alerted every time a new temp or symptom is entered – the next morning.

The possibilities seem endless. I think the big goal for Kaiser now is to get folks engaged and using these new access points.

Right now,  healthcare organizations have to go through some pretty tricky maneuvers to link patient data across varied systems and settings.  It’s possible to connect patient info electronically through database hacks, but more often than not, matching patients to clinical data gets done by hand.

Given the insane complexity of the existing system, would it make sense to create a national patient identification number for every U.S. patient?  The question is worth revisiting, given the immense level of error and wasted time generated by the existing system. After all, not only would putting an NPI in place make it easier to track patients within a hospital or health system, it would simplify the rollout of HIEs dramatically, wouldn’t it?

Dr. Robert Rowley of EMR vendor Practice Fusion notes that the biggest enemies of establishing a National Patient Identifier are privacy advocates who feel that an NPI would expose patients to greater risk of breaches or misuse of data.

But is that a realistic concern? Probably not. I agree with Dr. Rowley, who asserts that it’s hard to imagine that PHI would be at greater risk simply because of how it’s indexed.  As he notes, PHI breaches are nearly always often haphazard affairs in which a laptop is stolen than Big Government or corporate conspiracies. (If you’re afraid the government is covertly siphoning your health data off to study it, not having an NPI won’t protect you, anyway.)

No, the real barrier to this kind of administrative simplification measure is time, money and resources, the same barriers that hold back any other proposed HIT project.  It’s hard to imagine the resources that would be involved in instituting such a system — the idea makes my head hurt — and I have to assume it’d be several years before it was anything like mature.

Still, it’s good to bear in mind that at least some members of the public are afraid that creating an NPI would compromise their privacy. If the only barrier to improving patient matching in our EMRs is technical, that’s one thing — but if it’s patient fears, that’s another thing entirely. Sometimes, it’s good to remember that most of the world doesn’t think like a health IT exec.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I can’t believe that this is the last post in the series. I think it’s been a good series chalk full of good tips for those looking at implementing an EHR in their office. I’d love to hear what people thought and if they’d like me to do more series like this one. Now for the final 5 EMR tips.

5. Automatic trending helps all over the place – A picture is worth a thousand words and this is never more true than when we’re talking about trending. Make sure your EHR software can quickly take a set of results and/or data points and graph them over time.

4. Keep training over and over – Are you ever done learning software? The answer for those using an EMR is no. Part of this has to do with the vast volume of options that are available in EMR software. However, the training doesn’t necessarily have to come from formal training sessions. Much of the training can also come by facilitating interaction and discussion about how your users use the software. By talking to each other, they can often learn from their peers better ways to use the software.

3. Infrastructure is key to performance – I love when people say “My EMR is Slow” cause it’s such a general statement that could have so many possible meanings. Regardless of the cause of slowness, the EMR is going to get the blame. For those wanting to dig in to the EMR slowness issue, you can read my pretty comprehensive post about causes of EMR slowness. I think you’ll also enjoy some of the responses to that EMR slowness post.

Infrastructure really matters when someone is using an EMR all day every day. There’s no better way to kill someone’s desire to use an EMR than to have it be slow (regardless of who’s responsible).

2. Quit pulling charts as soon as possible – I think this tip should be done with some caution. In certain specialties the past chart history matters much more than in others. Although, it’s worth carefully considering how often you really look through the past paper chart in a visit. You might be surprised how rare it is that you really need the past paper chart. If that’s the case, consider only pulling the chart when it’s needed. If you only find yourself looking through the past paper chart for 2 or 3 key items, then just have someone get those 2 or 3 items put into the EMR ahead of time. Then, it will save you having to switch back and forth. Plus, then it’s there for the next time the patient visits.

1. Crap process + Technology = Fast Crap – Perfect way to end 101 EMR and EHR Tips! I like to describe technology as the great magnifier. The challenge is that it will magnify both the good and bad elements of your processes. Fix the process before you apply the technology.

If you want to see my analysis of the other 101 EMR and EHR tips, you can find them all at the following link: 101 EMR and EHR tips analysis.