Welcome to EMR and EHR

I’ll admit to being a huge fan of contests. What can I say? I love to win free stuff. I think everyone does. Plus, I love pretty much any competition. However, today when I read about the Cerner and CDW Healthcare EMR Technology transformation contest, something didn’t feel quite right. I’m sure it’s just an extension of the Cerner and CDW Healthcare EHR partnership, but let’s take a look at some of the details.

Sure, it’s great that they’re giving away $50,000 in EMR software and technology. They’re also partnered with Lenovo, Intel, EMC, Brother, Canon and Nuance. I like all of those companies for the most part and so the technology will be great. I’m just not sure winning a contest is the right way to decide to use that EMR software.

You can read more about the details at the contest website, but basically it will be in 2 rounds of judging. Here’s a description of the first round of judging:

Round 1 Judging: A panel of qualified judges comprised of representatives of each of the Sponsoring Vendors (Brother, Canon, Cerner, EMC, Intel, Lenovo and Nuance) will review and evaluate each eligible entry on the basis of the following criteria: (a) demonstrated need of Company for an electronic medical record application and an overall technology makeover(40 percent); (b) creativity of submission (20 percent); and (c) perceived ability of CDW Healthcare in conjunction with the sponsoring vendors, to improve productivity of entrant’s Company through installation of a medical record-keeping system and upgraded technology(40 percent).

The second round the vendor sponsors will do site visits to further evaluate your clinic. Not sure how this is going to work. Are they planning to select the clinic with the least amount of tech that will likely have a hard time implementing an EMR and going through all the changes? Or will they select the company who uses technology, but hasn’t yet implemented an EMR? The second clinic might be better prepared for an EMR implementation. Seems like all a marketing ploy without much thought for who they really want to award the prize to that will have the best impact.

I also think it’s interesting that they plan on parading the 3 finalists around at the HIMSS conference. Ok, maybe it’s not quite parading, but that’s kind of what it feels like. I looked through a lot of the official rules and didn’t see anything that forces you to implement the actual EMR. Seems like the form is simple enough to fill out that it might be worth getting all the technology for free. Plus, the free trip to the HIMSS 2010 annual conference might just be worth the entry. Then, you can have a chance to compare a whole bunch of EMR software. Not sure what Cerner will think about that, but maybe that’s the reward for not winning.

I previously did a post about some of the problems with Vista-FM. I considered that it was different than Vista, but wasn’t sure completely. The beauty of blogging is that when you make mistakes smart people come and correct you in the comments. This is one of those times. Plus, along with helping me understand the difference between Vista and Vista-FM Chris Richardson, provides an update on some of the other things happening with the open source community around Vista. I don’t agree with everything he says, but it’s definitely interesting. The following is Chris’ comment:

You jumped at the wrong conclusion when you jumped on VistA as being the faulty item here. What has failed is the “-FM” portion of the GAO report, the Foundation Modernization. You see, VistA is NOT VistA-FM. VistA-FM is the effort to dismantel VistA. Just like all of the other Attempts in the past nearly 20 years, these efforts are under-functioned, over-priced, and way over their delivery schedule. A mere fraction of the cost of what has been expended to replace VistA would have made VistA able to totally out-class every other approach to EHRs. There is work currently going on in the Open Source community to extend VistA and it is working very well. Here are some of the projects that are currently on the way or already in production;

Lab, while the VA is outsourceing to Cerner (with interesting results), the rest of the community outside the VA is continuing on with enhancements and options that will make it easier to install and higher functioning as well as affordable to nearly everyone.

Continuity of Care Records and Data (CCR/CCD) while this standard is a bit anemic, it does promise that we might be able to project all of the VistA databases to other systems or accession data from others.

Holographic EHR – This is one of our concepts, basically you could think of it as “VistA for One” (or a small group of patients), a self consistent subset of the parent VistA environment which could be booted separately. The self-consistent “VistA for One” becomes a mechanism for complete transfer of patient data from one site to another with merge capability. It also becomes an in-hand user copy of his records which can be protected via a network keying system which registers the data set, and records the efforts to open the data set and by whom, and who is attempting to accession the data to what target VistA system.

CPRS
This is fun. I cannot tell you the number of times that I have heard, we need to keep CPRS, but get rid of VistA. The engine behind CPRS IS VistA. Without VistA, CPRS is a screen-saver. The Open Source Community is making enhancements for the CPRS/VistA environments. There is another group that is working on the webification of VistA with open source tools.

By the way, I worked on the proposal team for CHCS-I and we used MUMPS to build interfaces for various other vendors to communicate with each other. In fact, the MUMPS interfaces worked better than the Clover-leaf connection engines.

There is a reason that the Subject Matter Expert developed systems of the VA, DoD, and IHS have been so effective and difficult to replace. VistA is a whole enterprise solution that the vendors hope you never find out about. The vendors focus on dismantling VistA to provide a new niche to build “customer loyalty” (make it too painful and expensive to move to something else so the customer is essentually stuck with the vendor’s solution only. With the VistA model the SMEs are the folks at the point of care, and not a programmer who has never spent an hour in a hospital, yet is charged with the setting of policy for the hospital in his interpretation of the requirements (which may or may not reflect the intent of the SMEs).

By having VistA as Open Source, this means that the cost of doing development has dropped right into the basement. Success can be tried in a thousand places, but with Open Source, as soon as someone comes up with an enhancement or corrects a problem, the change can go out to the rest of the World. The best of breed solutions float to the top to be applied everywhere.

You know, VistA is still running the VA hosptials for over 30 years, don’t you think that if the vendors could have replaced it, they would have? They have tried and gotten paid well for the attempts. But this is part of the problem. There is no incentive to ever complete a task or attempt because then the paydays end. This is why they have confused the community with the use of VistA-FM, use their failures as justification to try to replace VistA yet again.

Let’s take a look at some of these magnificent failures. How about the replacement of IFCAP (the financial part of VistA) with Core-FLS. Now get this. The VA developed IFCAP (by the way, it was not vendors who did this work, it was the VA SMEs who did the daily work of inventory and supply and finance) and owned the code. The VA paid nothing for the code other than the VA programmers and SME’s time. Then they were going to replace it with a package which would only have to do 30% of what IFCAP did. Congress committed $470 million to replace something the VA already owned with something that had less functionality but was more glossy and the VA would have to pay big bucks to the vendor to support. The roll-out of the product was done at Bay Pines VA Medical Center and was so bad that they had to close elective surgery. The vendor spent over half the money just to install the first site and the project was mercifully stopped and IFCAP was re-installed. So much for modernization. This is not an isolated incident.

There was the Spanish Pharmacy labels. Peurto Rico and many of the boarder VA Medical Centers needed to be able to produce Spanish Labels for the Hispanic Patients. This was done by duplicating code rather than completing Internationalization that was started back in the early 1990′s, but stopped by the Clinger-Cohen Act. It would have taken less time and less money to complete internationalization for all of VistA than it took to do a one-up parallel code base for Spanish Pharmacy Labels. Adding another language would mean even more complexity (such as French or German), would be even more duplicate code for a single functionality. By myself, I built a tool to convert all of VistA into being ready for Internationalization and made it so there could be any number of languages that could be selected by the user and not necessarily locked to a single language. It takes about 50 minutes to parse all of VistA into the instrumented code and load the DIALOG file with the words and phrases, ~165,000 phrases in all on a 800 mhz laptop. It does not modify the distributed code but builds the instrumented code in a separate location. This code is available for free download from WorldVistA.

The community is alive an well, and vibrant with new ideas. We are starting to catch up from the “legacy era” and allowing the evolution of the tools to progress again. Want to join in?? It is a lot of fun and a set of real challenges that will bring the power of what needs to be done, back into the hands of the people who are at the point of care. Interesting thing about the word “Legacy”, people think of it as old or non-functional. It really isn’t. It also means that the code is doing the job and doing it just fine. Can it be improved, sure, VistA was made to be improved, to expand beyond what was known and what was learned. But, do remember, VistA-FM is NOT VistA, it is the attempt to break up the integrated hospital system into a series of stove-pipes. VistA-FM is the worst of all FUD (Fear, Uncertainty, and Distrust). VistA is still running the hospitals and it is running more community hospitals every year.

The things going on in the EMR industry right now are really quite amazing. First, we hear about the Walmart EMR and then Dell comes out with a Dell EMR. Then, Dell acquires Perot Systems to add to their portfolio of services and software. That’s a lot of big name companies joining in on the EMR fun.

Now it’s been announced that Cerner and CDW are joining forces to Sell EHR and “offer a single touchpoint for EHR adoption.” Here’s a portion of the email I received:

Beginning November 1, CDW Healthcare will offer Cerner Corporation’s ambulatory EHR solutions to physician practices. The collaboration, which marks the first time the complete suite of Cerner ambulatory solutions for physician practices will be available through a national channel partner, will provide practice managers with a single touchpoint for hardware and software procurement, technology expertise, solutions guidance, and deployment services.

It’s an interesting partnership to have a hardware vendor join with a software vendor like this. I guess CDW also sells software, but usually it’s off the shelf mass market software. At the end of the day this is all about more sales channels for Cerner.

The most important question is which big company will be the next one trying to cash in on EMR software?

This story is pretty incredible:

A new care record system has contributed to thousands of patients from Barts and the London NHS Trust potentially breaching the national 18-week referral to treatment time target.

The trust is facing a backlog of 23,000 potential breaches, and although it says the situation is improving – and it has resumed reporting on 18-week waits – it may “fail for the delivery of 18 weeks in 2009-10”.

Problems with the Cerner Millennium CRS, combined with poor trust data and procedures, are responsible for the problems.

In August, the backlog of admitted patients stood at 1,700. The trust also reported having a “non-admitted backlog of 26,640 on pathways”. This required validation as many were duplicates. The number has since reduced to about 23,000 cases.

The problems date back to the implementation of Cerner Millennium last April. By September 2008, the trust was projecting a £3m shortfall in income due to data, reporting and technical problems with its BT-provided system.

The trust has since introduced new systems and processes to manage patients and an 18-week patient tracking list. These are backed by weekly review by each speciality within the hospital. Trauma and Orthopaedics is the speciality with the highest number of backlogs.

The trust says that the sheer scale of case backlog will make it very difficult to clear, with seeing and treating patients likely to lead to a “dip in performance”.

The scale of the problem means some patients may be kept waiting for more than six months, twice the national target for treatment. An August trust paper states: “It was acknowledged that 26-week breaches may occur due to the quantum of the non admitted backlog.”

EMR is great when it works, but when it doesn’t this type of stuff happens. Although, it’s really hard to imagine missing 26,000+ cases. WOW!