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

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

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

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

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

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

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

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

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

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

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

Most of the charts look like:

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

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

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

“Meaningful Use” is “meaningless” to clinicians.

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

Here’s my list:

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

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

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

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

Doctors are not Technology Averse, they are Stupidity Averse.

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

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

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

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

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

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

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

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

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

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

In response to my post on CCHIT’s comments on the EHR Certification criteria, I got an email from Ryan Ricks. Ryan works for XLEMR and shared the following perspective on EHR adoption (or lack thereof) and the effects of the EHR stimulus money on it.

I do not want to delve into politics, but I think this is a classic example of what happens when government intrudes upon the private sector. Rather than speeding up EHR adoption, this whole process has caused the market to grind to a standstill because physicians are waiting for all of the details to become final. I’m sure other small companies have been negatively affected by this, not just us.

It has been very difficult to convince physicians to buy. I think physicians as a group are more concerned with avoiding the risk of purchasing a non-compliant system – rather than motivated by the reward of the stimulus money. Furthermore, we have noticed a significant lack of trust in the government. Many physicians don’t believe the money will be available, or they are worried about the “strings” that are attached. In addition, several physicians expressed a great deal of concern over the interoperability requirement – they want to protect their patient’s privacy.

Sadly, what Ryan describes is basically what I’ve seen happening with EHR adoption as well.

SRSsoft, an EMR vendor, put out an interesting press release putting the lost democratic senate seat in Massachusetts with healthcare reform and EHR adoption. Here’s a quote from the press release:

“The question is not whether we need healthcare reform,” says Evan Steele, CEO, SRSsoft. “Rather, the voters voiced their concern that reform must benefit consumers and physicians, not just government, insurance companies, and vendors. This election must open the government to input from all stakeholders, and that is a good sign for the constituents of SRS—the physicians—who feel that their voice is not being heard on healthcare reform and on EHR adoption.”

Honestly, I don’t see the change in the Senate seat affecting EMR adoption at all. However, I think it will have a big impact on healthcare reform. I’ve said before that the healthcare reform has opened our eyes to the government processes in ways we’d never seen before. I think that the HITECH act has done much of the same for those of us interested in EMR legislation and rule making.

Recent stimulus-induced EHR deals show sooner-than-expected adoption, especially in the hospital sector, according to investment firm Piper Jaffrey.

The second half of 2010 and all of 2011 are likely to show a large number of EHR deals, Piper Jaffrey analyst Sean Wieland wrote in his analysis Friday.

Wieland noted a growing trend of hospitals buying or subsidizing EHRs for physician practices.

“We continue to believe that mega-deals will continue as hospitals seek to capture first-mover advantage and HHS’ finalization of stimulus criteria will act as a catalyst for stand-alone physician/group practices to jump into the deal foray,” he said. -source

I’d be interested to know where Piper Jaffrey got their numbers that support their conclusion that EHR adoption showed better adoption in late 2010. I guess maybe they’re comparing their numbers to what they thought it would be. Maybe they expected adoption to be close to 0 and it was just over that.

I do think that Piper Jaffrey is dead on when they say that EHR deals will see a huge increase in 2010. It’s going to be the season for EHR adoption.

Do you think that the “mega-deals” involving hospitals subsidizing the EHR will be the reason?

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%)

Here’s a short summary of a survey on the impact of EHR adoption and the major challenges of EHR implementation:

Stamford, Conn.- based IVANS Inc., a provider of electronic communications services to insurance and healthcare companies, surveyed 508 healthcare providers throughout the United States in April 2009.

According to the survey providers do see the benefits of healthcare IT, with 66 percent of those surveyed believing that EHRs can have a positive impact on their business, and 74 percent believing EHRs can have a positive impact on the healthcare industry overall.

The biggest challenge to implementation cited by providers was, “lack of budget” (82 percent) followed by “lack of awareness and expertise.”

I’m not sure how well this survey was executed, but the results seem to match what I’ve experienced in the EHR industry as well.