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’s a proposal that could make Meaningful Use standards and vendor certification programs more valuable. Authors writing for the Journal of the American Medical Association have suggested that the Joint Commission’s National Patient Safety Goals for 2011 be included in EHR certification and MU criteria.

Here’s how the JAMA authors suggest linking EHR standards with the NPSG list:

* Patient identification:  EHRs can and should make patient identification more reliable, in part by including patient photos. EHRs should also require caregivers to re-enter patient initials if patients seem to have similar names, the comment suggests.

* Physician notification:  EHRs should not only ping physicians when a patient has abnormal test results, but also require doctors to respond by a given deadline, according to the article.

* Improving medication safety:  As long as they don’t warp clinical workflow and create additional risk of error, EHRs should support bar code med administration and clinical decision support, the JAMA authors say.

* Infection control:  EHRs should track patients with dangerous infections, and also offer checklists which can improve clinicians’ compliance with IC protocols, according to the proposal.

* Medication reconciliation:  One of the most obvious ways the NPSGs, Meaningful Use and EHRs can work together is to support appropriate med reconciliation, particularly by improving interoperability between med lists across organizations and varied EHRs, the writers suggest.

* Suicide risk:  Here’s an intriguing idea. The authors argue that EHRs should include a checklist to assess risk for patient self-harm, as well as notifying clinicians for patients who should be screened for depression.

As an analyst, rather than clinician, I don’t have any direct comments on the list of safety proposals. But I must say that from my perspective, this approach seems smart, practical and even better, focused.  Adding specific patient safety goals to EHR standards — rather than debating over broad safety issues — looks like a great idea.  Am I missing something here, or do you share my enthusiasm?

For several years, I’ve been citing dismal statistics on the growth of health information exchange networks. Perhaps, back then, I was too hard on them. After all, fledgling, starry-eyed HIE groups were facing tough odds, given how few physicians and hospitals were even wired enough to support their efforts.

Fast forward to today, and it seems little has changed. Though hospitals and medical practices are going online in large numbers, the HIE business model still seems to be shaky.  The latest evidence of this comes from a study from the Harvard Business School, which concluded that — surprise, surprise — that most HIEs still aren’t financially viable.

The study, which collected survey results from 165 HIE groups, concluded that just 75 of these organizations were actually up and running. Those 75 groups are probably working very hard, but still only reach 14 percent of U.S. hospitals and three percent of smaller medical practices. And get this: only three of the 75 groups offer a data exchange model which supports Meaningful Use standards. Wow.

Not only that, most of the HIEs studied don’t seem to have a sustainable business model. Two-thirds of the operating HIEs ended up in poor financial shape once they burned through initial hospital and physician funding, the study’s authors found.

Now, it’s worth noting that the study’s authors collected their data in late 2009 and early 2010, and heaven knows EMR penetration, interoperability and health data exchange are moving targets. If HIEs were just starting out now they might have had more momentum.

The unfortunate truth is, however, that HIEs have faced a nasty chicken-and-egg problem; if they wait for providers to get up to speed they’dllnever get rolling, but they’re having trouble making it without enough provider support.

At some point, the provider community’s going to have to decide how serious it is about data sharing, and whether leaders are willing to invest in this model over the long term.  Waffling, posturing and playing chicken (i.e. “let’s see if anyone else is willing to spend money on this”) obviously aren’t going to work.

Here’s a theory I’ve been working on — one which I’ve come to doubt — but I’ll put it out there anyway and see what readers think. As I’ve watched the slow, painful process of physician EMR adoption, I’ve had the sense that primary care physicians were under the most pressure to move ahead and were likely to lead the parade.

Sure, everyone has their eye on HITECH incentives, but primary care doctors have even more to worry about. For starters, they have a more challenging  population management task at hand.  Now, they’re under even more pressure, being expected to provide a “medical home” for patients, do more monitoring of their condition, coordinate specialist care and check up on patients’ compliance with preventive health measures.

In theory, PCPs can do such monitoring on paper, and some actually do.  But one can only assume that it’d be easier to manage these increasing levels of responsibility  – and to provide the extensive quality data health plans demand — if they get an EMR in place quickly.

Sure, I hear plenty about specialist EMR adoption, and technology for specific specialty niches, but my gut feeling has remained that primary care doctors have the most to lose if they don’t move quickly.

However, search though I might, I can’t find any anecdotal or statistical data to support my conclusion, so maybe I’m way off here.  Folks, what are you hearing?  Are primary care doctors adopting EMRs at a faster rate than their specialist colleagues, or are specialists picking up the ball at a similar pace?

In all my years writing about healthcare and technology, I’ve never seen such a storm of enthusiasm over a new medical device.  If the newspaper and blog coverage is any indication, we have no less than a moral duty to give an iPad to every practicing physician, stocked with a variety of the coolest medical apps.

In fact, Apple itself has jumped on the bandwagon, with its most recent iPad2 commercials displaying medical apps.

This, of course, has serious implications for EMR developers.  If the iPad is eclipsing even the desktop and smartphone as a primary means of accessing medical information, their focus will have to shift from a traditional client-server model — and perhaps even existing SaaS options — to one which is more modularized.  Their assumptions  about users’ interaction with their interface will need to be different as well.

The thing is, despite all of this discussion, I’ve seen no stats to back up the notion that even tech-friendly doctors see iPads as indispensable.

Where the iPhone (or at least smartphones generally) are concerned, sure, there seems to be plenty of research documenting that most physicians rely on them. But while there’s lots of anecdotes circulating about the iPad’s central future in medicine, none of the research firms covering the healthcare industry seem to have documented this trend.

What’s more, as a consumer whose family sees a lot of specialists — a few of us have chronic illnesses — I’ve never seen an iPad in anyone’s hands.  Walk into a coffee shop in the prosperous D.C. metro suburbs where I live, and sure, at least one consumer will have one.  But in DC medical offices, not so much.

Now, don’t get me wrong, if I were a product manager with an EMR vendor, I’d create an iPad interface and trumpet its existence to the world — it makes marketing sense if nothing else. One vendor which has already taken this tack is DrChrono, which prominently advertises the iPad version of its free EMR.

Regardless, I’m still waiting to see more evidence that the buzz around the medical iPad is more than just the expertly-crafted legends Apple creates around its products.  (Should we sense some Pixar magic here?) Anyway, just because everyone says something’s cool doesn’t mean it is.  I mean, we learned that in high school, didn’t we?

For years, public health officials and health leaders have been sounding the praises of EMRs, arguing that patients would enjoy safer, more effective care once providers went digital.

For a while, it was a tough sell, with surveys repeatedly suggesting that patients were suspicious that their data would be compromised or shared without their permission. Others seemingly just weren’t impressed with the concept.

Of late, however, it seems that the public has caught up, and may be well ahead of the provider community in its enthusiasm for digitizing medical records.  According to a new survey by GfK Roper, 78 percent of patients believe an EMR will allow doctors to give them better care whose doctors use EMRs believe that it helps the doctor provide better care.

According to Practice Fusion, an EMR vendor which backed the survey, patients are eager to get e-mailed appointment reminders, have their prescriptions sent electronically and view appointments online.

But wait a minute. Even if backing by a vendor hasn’t tilted the results, this kind of study doesn’t necessarily mean that patients really want an EMR as such.

My guess is that the folks surveyed by Roper have caught wind of a few cool things that more advanced medical practices and hospitals are doing (such as telemedicine, making test results accessible online and appointment scheduling) and they want in. Everybody likes convenience, no?

Somehow, I doubt they’re thinking about care coordination, sharing of medical records from one institution to another across an HIE, integrating data from various departments within a facility, creating data warehouses to do quality studies and so on.  They’re just starting to get a feel for the bells and whistles, some of which don’t even require an EMR to execute.

No, the truth is that it most Americans will never understand the clinical problems EMRs are designed to solve, as most will never delve into issues like risk analysis and patient safety management.  So their interest will inevitably flag.

But for now, we’ve got their attention. This is a moment — the EMR’s “15 minutes of fame” — in which the buzz is so intense that even consumers are getting excited.

Providers, now is the time:  Reach out and educate consumers on the value of your EMR investment while they’re still interested.  This moment may not come again.

UPDATE: As you’ll see above, Practice Fusion was kind enough to correct my understanding of a key part of of the study.  The idea that patients whose doctors already have EMRs in place are happy about it is different, of course, than saying that consumers generally want doctors to hurry up and adopt one. That being said, I’d still argue that even these patients are at a gee-whiz stage, and that their enthusiasm won’t last long. What do you think?

Caught an interesting analysis this week from the California HealthCare Foundation, which has been studying EHR deployment within community clinics and health centers since 2006.

In most cases, chart abstraction creates a major bottleneck which can slow the transition to EHR use to a crawl, while cratering caregiver productivity in the process.  But if it’s done thoughtfully, you can avoid some of the chaos, the study suggests.

In its new paper, the foundation shares chart abstraction techiques that used by members of its California Networks for EHR Adoption initiative.

Here’s some strategies CHCF has identified which seem to speed  up the process – and in turn, streamline EHR deployment. (This is just a small sample; I highly recommend you check out the paper itself for detailed case studies and advice.)

Some of the research group’s suggestions:

* Start with a strategy: Decide in advance what information will be entered, when, and by whom — and decide how closely the EHR data should resemble the paper version.  Just as importantly, decide whether any given piece of data is really worth entering at all.

* Don’t abandon paper too quickly: How do you abstract paper chart data?  Usually, you consider scanning charts, migrating data from legacy systems, entering data manually or going for a mix of all of the above.  While each can work, the key is not to drop paper charts too quickly.  To reassure staff, the clinics in CHCF’s initiative typically kept paper on hand all the way through the EHR go-live period — and sometimes for a while afterwards.

*  Fine-tune your abstraction approach: Clinics that did well with the abstraction process had make near-constant adjustments to their process.  For example, one clinic had to move quickly from traditional scanning to a software solution which gave the docs smart headers, after staff wasted countless hours poring over cryptically-named scans. Then, when that wasn’t enough, it had to develop a hierarchical naming system for scans not long after.

Readers, are you struggling with chart abstraction process as you prepare for EHR deployment?  Has staff productivity taken a big  hit?  Perhaps most importantly, how long do you think it will be before the paper-to-electronic- data process stops being an issue?

Today at HIMSS, the findings of a research study by the FCC was released.  I find it pretty interesting that the FCC is looking at healthcare IT.  The research study did an analysis of the healthcare IT infrastructure and its ability to support the growth of helathcare IT. Here’s a short summary of their findings:

FCC research has found that the current broadband available to physicians is cost prohibitive and can be a barrier to important developments in health IT.

• Physician offices with less than 5 doctors can have their needs met by currently available commercial offerings, usually at a reasonable cost. Even so, roughly 3,600 small practices lack access to even the basic broadband services they require to achieve Meaningful Use.
• Practices with more than 5 practitioners face a larger challenge. They need a higher level of broadband, and tens of thousands of offices in this category face prices that differ significantly, often by $45,000 or more per year for the same level of service. The gap is substantially larger for rural providers

These disparities offset meaningful use incentives and can prove to be a barrier to health IT adoption.

The FCC plans for a major expansion in its efforts to bring high-speed broadband service to healthcare providers. The program is authorized to spend up to $400 million per year, making it the largest sustainable fund for healthcare connectivity. Currently the FCC only spends approximately $70M per year of the $400M due to limitations in how it is authorized to spend the funds. Funds can currently be let through:

–   The Rural Healthcare Support Mechanism subsidizes telecommunications expenses of rural non-profit and public healthcare providers that face higher broadband prices than their urban counterparts. Also covers 25% of the internet service fees

–   Rural Healthcare Pilot Program—a one-time program with 63 projects (totaling $417M) to build dedicated healthcare broadband networks

National Broadband Plan Recommendations:

The FCC would like to substantially expand broadband subsidies to healthcare providers where service is unaffordable, including in urban areas. FCC is requesting a change to improve the health IT infrastructure, including:

• Allowing private institutions to be eligible for funding (not just non profits and public institutions)
• Supporting deployment of new broadband networks where they are insufficient by creating a permanent infrastructure program
• Linking FCC funding to outcome metrics such as “Meaningful Use” to ensure support goes to locations that use health IT in support of guidance from the Office of the National Coordinator for Health IT

At the same meeting where Google’s CEO, Eric Schmidt, commented about healthcare IT, there was another interesting comment by Eric Lander about the state of researching EMR and healthcare IT. Here’s his comment:

“My sense is that we don’t respect this stuff,” said PCAST co-chair Eric Lander. “We respect the cancer genome, but not checklists. What do we need to do to send a signal to the next generation of researchers that this is a high-class, worthy thing to do? What would it take to move the needle?”

I agree. I’ve done the searching through the journals for well done EMR research and found very little. Not that research is the end all be all, but it can provide insight that can’t be found other ways.

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%)