The always interesting and passionate Al Borges, MD posted a comment in response to my post from over a year ago about EMR tire kickers and EMR Adoption:

>>> “I think we’re going to see a tremendous increase in EMR purchases at that point in time.”

Why did you believe this back then, John?

Doctors aren’t stupid- most won’t throw themselves at MU’s $44,000.00 only to be left straddled with a loss from year 1 due to the estimated costs of owning an EHR and doing MU for eternity of $40-60,000.00 per year.

Time has shown that the HIT industry has stagnated, with few doctors now buying into the politically driven HITECH Act. I can’t wait until the next CDC biyearly report…

Here’s my response to Al’s comment:

Al,
I still think that statement’s true. There’s going to be a spike in those that purchase EMR software to get the EMR stimulus money. Many were already considering buying it before the stimulus and now a good number of doctors will buy an EMR now that we have the details and timelines for the EMR stimulus.

After this jump in sales, it’s then going to be interesting to watch. The future sales of EMR software are going to be highly dependent on the experience of these initial EMR implementations. If they’re successful and doctors like their EMR and get the EMR stimulus money, then we’ll see more EMR adoption. If they don’t like it or have trouble getting the EMR stimulus money or experience many of the headaches of EMR adoption that we’ve seen before, then I believe it will actually set EMR adoption back long term.

I know which way you lean on that scale. I still think the jury is out, but I am concerned that the later scenario is a distinct possibility.

If the later scenario of an EMR adoption setback occurs, I’m not sure we’ll come out of it until the next generation of “digital natives” finish medical school and achieve prominent enough status in a clinic to push EMR adoption again.

I did misjudge the time it would take to really get the details of the EMR stimulus in place. I thought by February or March of 2010 we’d have known more than we did. Turns out the legislative details took much longer than I expected, but I think we’ll see the EMR adoption spike now that the details are finally in. At least that’s the view I see as far as action and interest in selecting and implementing an EMR.

What do you guys think? How is EMR adoption going and what EMR adoption trends do you see happening in the future?

I thought it would be fun to discuss the “real world” of what it’s like to use an EHR system. Here are a few misconceptions that, if you believe all the advertising and other hype, you might have about the benefits of using an EHR system. Although the promise is definitely there in terms of what should be feasible ideally, the real world often determines otherwise.

Misconception 1. “I walk out of the office at 5 PM with all of my notes done for the day.  Awesome!”

Maybe once every month I can do this, on a slow day. The fact is that all of the documentation that needs to be completed prior to signing a note usually cannot be done for all visit notes by the end of the day. There are a variety of issues. Patients throw you curve balls on the way out the door. Patients have complex issues that you need more time to research prior to finalizing your plans. Patients forget information that they want to call you back about later, e.g. missing medication names and doses, doctor’s names that they want you to cc:, etc. On busier days, when patients come in late and you end up juggling appointments to avoid refusing to see anyone (this is private practice with real cash flow needs after all!), or when the phone just ends up ringing off the hook with one urgent issue after another, signing all your notes by 5 PM becomes impossible.

Misconception 2. “It’s a breeze to electronically send all my prescriptions. I don’t need a scrip pad anymore!  Woohoo!”

Mail order pharmacies destroyed this one with all their forms. Three-quarters of the patients in this category need me to fill out a paper form to fax in. The other 25% need paper scrips written out, typically five to ten at a time, so that they can mail them in themselves. Auto-renewal requests come in by fax every day, needing to be filled out and faxed back. My personal revenge comes in the form of being able to fill most of these out using my PDF editor software prior to faxing them back without touching a single microdot of ink to paper.

Misconception 3. “I don’t have to dictate anymore.  Yippee!”

For all new patient visits, I end up dictating at least the history of present illness (i.e. “HPI”, the first paragraph or two telling the patient’s story for those of you unfamiliar with this terminology). Although I can eliminate paying for this service by using a free iPhone app (Dragon Dictation), I still have to go through the process of speaking and then editing the notes. The alternatives would involve me sitting there wasting huge amounts of time typing details into a paragraph or two for each patient, or I would end up doing what I see some of my referring docs do, which is to type in VERY brief notes that eliminate a lot of important details just to get by and move on to the next patient. Some contrarians might suggest that everything can be done through templates, which is partially true to some extent, but everyone’s story is unique and different, especially when you are dealing with subspeciality areas such as disorders of the thyroid and adrenal glands.  The last time one of my patients had run-of-the-mill chest pain that could be reduced to a series of templated checkboxes to adequately describe their story was … well… never.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009. Check out all of Dr. West’s EMR Doctor’s Blog posts.

This is the third post in the series of posts(see the previous ONC-ATCB Certified EHR Breakdown and ONC-ATCB Certified EHR Breakdown by Certifying Body) looking at the EHR certification numbers put together by HITECH Answers. The following is a list of Certified EHR products by vendor:

Top 3 Vendors by number of Products Certified
- Cerner Corporation – 13 products
- Siemens Medical Solutions USA Inc – 9 products
- Epic Systems Corporation – 4 products

I guess these are the EHR software you want to avoid. Ok, that’s partially facetious. Just, can you imagine trying to battle the other 12 certified EHR to get support. Granted, most of them are likely hospital EHR and so there are usually support contracts in place to deal with this kind of thing. Don’t worry though, Allscripts should be on this list soon. I think they have something like 7 EHR software for just ambulatory right now. I guess that’s the nature of acquisitions.

It will be interesting to continue to see this evolve.

This is the second post in the series of posts (see the previous ONC-ATCB Certified EHR Breakdown) looking at the EHR certification numbers put together by HITECH Answers. The following is the breakdown of EHR Certification by Certifying body:

2 Certified by Infogard
- 1 Modular Ambulatory system
- 1 Modular Inpatient system
40 Certified by Drummond
- 15 Complete Ambulatory systems
- 5 Complete Inpatient systems
- 15 Modular Ambulatory systems
- 5 Modular Inpatient systems
88 Certified by CCHIT
- 50 Complete Ambulatory systems
- 15 Complete Inpatient systems
- 11 Modular Ambulatory systems
- 12 Modular Inpatient systems

Infogard is just getting started, but CCHIT and Drummond Group are cranking them out. I’m guessing right now demand for their service is strong and they can certify them as quick as they can. It will be interesting to see what happens to these organizations post EMR Stimulus money, but they have a few years before they have to worry about that.

Of course, this is only the temporary ONC EHR Certification. ONC will have the official one and then all the EMR vendors will likely have to re-certify again. Let’s call it the EHR certifying body stimulus program.

Many people were worried that we wouldn’t have many certified EHR available for 2011. I wasn’t one of those people, but they were out there. Seems to me that this really won’t be an issue at all. There’s 130 partial or complete EHR companies on the official ONC certified EHR list. That’s a lot of software and it’s only the beginning of December. I expect we’ll have 200 or so more ONC-ATCB certified EHR software by the first quarter of 2011.

The good people at HITECH Answers have done the hard work putting together the number of systems certified. Check out the numbers:
85 Complete EHR
- 65 Ambulatory systems
- 20 Inpatient systems
45 Modular EHR
- 27 Ambulatory systems
- 18 Inpatient systems

That’s right. 65 Complete Certified Ambulatory EHR. 27 other modular certified EHR and I’m sure that many of those are just doing the modular as a stepping stone to the full certification.

We have all seen medical records from an emergency department (my apologies to the blissful ignorant out there — you don’t want to know if you don’t already). Much like sausage, they come out pretty much all ground up, full of information that at first glance can be difficult to figure out. If you find yourself asking questions such as, “Where is the part about why the patient came in and what the doctor thought about their case?” then you just might have one of these notes. They’re actually one of my favorite types of “old medical records” to sift through for the purposes of “reviewing and summarizing”. This is because when you’re dealing with gobbledygook, well, there’s not much to summarize. It’s easy to flip through forty or fifty pages in no time and say that you have honestly reviewed and summarized the old records, which are full of near meaninglessness that doesn’t impact my decisions in the patient’s care much, if at all.

The ER notes (and many primary doctor visit notes nowadays) result from having programmers who don’t appear to understand the appeal of a well-written note in facilitating basic communication. Computer programmers who get their hands on the list of required information that must be put into a note to pass by insurance standards don’t always design good products. Unfortunately, this really only highlights the insanity of criteria for medical documentation to gain the golden eggs of insurance company reimbursements for providing medical services. I’ll save those crazy criteria for some other day. Nonetheless, the tax man and the gobbledygook cometh. If only they had the guidance of a practicing physician in the design process!

Unfortunately, as the gold rush for economic stimulus dollars ramps up, poorly designed systems will most assuredly continue to be thrown onto the market. I recommend to anyone considering incorporating an EHR system into your practice that you actually consider and request to review a sample of the output format. If it looks like something that would embarrass you to show your former mentors from the residency or fellowship program in which you trained, then I would posit that this is probably not fit for medical documentation. If no one wants to read what you wrote, then is it really worth doing? And please don’t be fooled into thinking that spending more money is the key to getting a better product. Ask the EHR vendors to put their money where their mouth is.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

I’ve discussed on multiple occasions the possible impacts of the congressional changes on the EMR stimulus money. Justin Barnes on The Health Care Blog recently posted the best reason I’ve seen yet for the EMR stimulus money and meaningful use being safe from being cut, stopped, or otherwise maimed due to some political change. Here’s his description:

Fundamentally it’s important to note that the Health Information Technology for Economic and Clinical Health (HITECH) Act, from which the Meaningful Use program and its funding originates within the American Recovery and Reinvestment Act (ARRA) of 2009, is an entirely different statute than PPACA.

Bipartisan support for the tenets and the spirit of HITECH dates back at least seven years, and it is also noteworthy that the Office of the National Coordinator for Health Information Technology (ONC), which administers Meaningful Use, was created by the Bush administration and a Republican Congress.

Politics aside though, the reason that Meaningful Use funds are secure is because they are drawn from the Medicare Trust Funds held by the U.S. Treasury, and are therefore not subject to annual Congressional budget appropriations or oversight.

From what I’ve read, the funding is really the only tool that the republicans have to damage the various democratic legislation that they don’t like. Since the meaningful use funds are part of the Medicare Trust Funds and not subject to the congressional budget, I think that clearly defines why the EMR stimulus money is safe.

So, you can all go out and safely buy your certified EHR and start showing meaningful use of your favorite EHR software.

HIMSS Analytics recently sent out some interesting results from a survey the did of hospital’s preparation for meaningful use. Here’s the results:

*Nearly one quarter (22 percent) of participating hospitals have the capability to achieve 10 or more of the required core measures in the meaningful use Stage 1 requirements.

*Some 34 percent of respondents have the capability to achieve between five and nine of the core measures for meaningful use.

*Just over 40 percent (40.47 percent) of the market indicated they have the capability to meet five or more of the menu items for meaningful use.

As lone data points it’s hard to judge if hospitals are making progress or not. I’ve heard many people say that hospitals are going full bore towards meaningful use and that ambulatory practices are slower to adopt EMR and meaningful use. I’m not sure this is totally true. Plus, the lead time needed to implement in an ambulatory setting is so much shorter than in a hospital. Even a hospital that owns ambulatory practices.

I’m told that HIMSS Analytics will be doing this same survey every couple months. I’ll see about publishing the results as I get them so we can compare the change.

Check out this 4 and a half minute video that talks about the details of the EMR Stimulus (HITECH Act) EMR stimulus money. This is by far the best EMR stimulus video I’ve seen that gives a nice high level overview of the HITECH act. I hope that they do some other similar videos with more details on meaningful use and certified EHR since this is the only meaningful use video I’ve found.

If you know a lot about the HITECH act, you won’t enjoy this video. However, doctors who don’t know too much about the EMR stimulus money and how the HITECH act works will enjoy it.

Gov Info Security recently published their thoughts on the possible effects of the new Congress on the EHR incentive money known as the HITECH act.

Republicans, however, have made it clear that they’ll look for any opportunity to repeal some or all of the healthcare reform package. Observers say that means the HITECH Act likely won’t get as much attention, even though the EHR incentives are funded by President Obama’s economic stimulus package.
“One of the things that the Republican ‘pledge to America’ includes is a plan to take away any unobligated stimulus money,” says Dave Roberts, vice president of government relations at the Healthcare Information and Management Systems Society. “I don’t think that’s going to apply to the HITECH provisions. Folks on the Hill tell me that health IT is a bipartisan issue. Democrats and Republicans see it as a way to improve healthcare.”

Nevertheless, Republicans will closely scrutinize all spending, Roberts acknowledges. “And they’re going to take a close look at all the provisions of the HITECH Act to make sure they’re being implemented as directed by Congress.”

Even if the presumed new speaker of the House, John Boehner, R-Ohio, was to push for spending cuts, such as eliminating the EHR incentives, getting such a proposal approved would prove very difficult, Roberts argues. “With the two chambers of Congress controlled by different parties, getting them to agree on something will be next to impossible,” he says.

In addition, President Obama, who is strongly supportive of healthcare IT, likely would veto any cuts in HITECH spending, notes Rob Tennant, senior policy adviser for the Medical Group Management Association. And overriding a veto would prove extremely difficult.

I tend to agree. Certainly something crazy could happen (it’s government work after all), but I think the likelihood of HITECH Act funding being taken away is pretty slim. As it describes above, it would take a really unique piece of legislation to get it through the house, senate and then the President. I just don’t see that happening at all.

Plus, I thought the point of the money being so far along in the regulation process is another good reason. Although, since checks haven’t been paid out yet, I’m guessing that there’s still potential that they’ll put it on hold. Just seems really unlikely to me.