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.

I came upon this comment from Kay Kirchler, MD in regards to the ePrescribing penalties and other government incentive money for health IT. You’ll have to overlook the poor grammar and abbreviations, but I wonder how many other doctors feel the way Dr. Kirchler does.

who made all these rules and why are we just lying down and taking it? the arbitrary requirement for “10 escribes ” by june 30th or “penelty” when our emr ( we have had emr for >>10 yrs) will not escribe due to delay in “retro-fitting ” our emr instead of spending yet another fortune for a new “government approved ” version. the requirement to print out visit note to be available w/i 3 days rule .. rediculous. pts dont want it , not going to pick it up, costly and opens door for pts info to be floating out in parking lots, garbage cans etc .. i could go on for days. i spend more time loading info in emr ( much more w “meaningless use” than i do taking care of the patient .why are we not organizing to stand up and fight this power grab !!!!

The line that gets me is the one where he says that he spends more time loading data into the EMR than he spends with the patient. As a patient, the idea of this just makes me cringe. However, it’s a reality for many.

The other part that is quite interesting is that there really haven’t been many physician voices in all of this. There’s definitely not been any #OccupyMeaningfulUse protests happening by doctors. The closest thing I’ve seen to doctors rising up against Meaningful Use and other government programs for health IT has been at medical association conferences where doctors have gotten quite worked up. However, the message rarely leaves the medical conference. Plus, the majority of doctors in the room just shake their head, but don’t do anything after that.

I imagine many doctors look at it and see EHR software as the inevitable.

I’ve blogged before about the importance of decreasing the digital divide in this country in order to truly move healthcare interoperability forward. As I mentioned last month, “Only those patients who have access to these digital healthcare technologies will begin to clamor for them at their next doctors’ visits. Only patients’ whose doctors in turn have reached out to them via email, text or social media regarding the switch to electronic medical records, development of health information exchange and the benefits to care these will hopefully bring will be ready and willing to go with the digital flow.”

When news came across my somewhat cluttered desk of Emdeon’s initiative to provide electronic health record (EHR) technology to physicians in New Jersey’s underserved communities, I first thought, “Yes! That’s what I’m talkin’ about!” Then I put on my journalist/blogger hat and thought, “Will this truly change anything in these particular communities, or is this just good PR?”

A quick bit of background: Emdeon is partnering with the U.S. Department of Health and Human Services’ (HHS) Office of Minority Health, New Jersey Health Information Technology Extension Center (NJ-HITEC), the state’s REC, and the HIMSS Latino Community. Through the initiative, Emdeon will donate Emdeon Clinician licenses to 100 healthcare providers who practice within medically underserved areas and/or healthcare provider shortage areas, as designated by the Health Resources and Services Administration (HRSA), according to a recent Emdeon press release. The company will waive the license fee for these physicians for one year.

The same press release also mentions “EHR adoption is lower among providers serving Hispanic patients who are uninsured or rely on Medicaid, and is lower among providers serving uninsured, non-Hispanic black patients than among providers serving privately insured, non-Hispanic white patients.”

The initiative sounds like a great idea, but the one-year stipulation got me thinking (a bad habit, I know). What will these physicians, who presumably can’t really afford this technology now, do after their year is up? I reached out to Miriam Paramore, Senior Vice President – clinical and government services at Emdeon, to learn more about the ins and outs of the program.

How did the initiative come about?
Miriam Paramore: During the fall of 2010, leaders from the Office of Minority Health (OMH) and Health Information Technology issued a public, written request to health IT vendors, asking them to pay special attention to healthcare providers within underserved communities. This initiative is known as The Alliance to Reduce Health IT Disparities. Emdeon is serving as a private partner with the OMH to offer access to health IT products and services to providers within undeserved communities in New Jersey. We were thrilled to volunteer and to work within these communities.

Has Emdeon ever done anything like this before?
We’re happy to do part of this effort with HHS and it is the first time we’ve partnered with them.  We have great empathy for the challenges of the physicians in underserved communities and we want to help.

What sort of challenges do small physician practices in underserved communities typically encounter?
In addition to challenges like poverty and health disparities amongst their patient population, providers in underserved communities and smaller practice offices face expensive costs associated with on-boarding EHRs. Emdeon created the Emdeon Clinician solution as an affordable EHR “lite” solution for these small practice physicians or those working in underserved communities. They now have an affordable, easy-to-use solution that will help them to qualify for federal HITECH stimulus dollars without unnecessary disruption and expense of a full-blown EHR system.

How will you work with these 100 physician practices to ensure they are able to continue using the donated EHR after the year-long license expires?
Once the 12-month period expires, providers will be able to continue using Emdeon Clinician for only $99 per provider, per month. Emdeon usually has a $500 implementation and training fee [that, for this program,] has been discounted to a one-time fee of $200 for the providers participating in this project. This is a considerable discount and the fee would only have to be paid once. We will begin outreach to these providers in advance of the expiration date so they are aware of the opportunity to remain with Emdeon Clinician for the low fee following the initial 12-month period.

How will Emdeon work with NJ-HITEC and the HIMSS Latino Community throughout this year to ensure that these practices receive continued training and support?
Emdeon has taken the lead with managing this initiative between all partners with monthly meetings to monitor progress. We have a dedicated project manager, who has mapped a process with the internal team to assist with implementing these physicians as soon as possible. Our custom phone number (1-855-840-7120) connects interested providers directly with a dedicated clinical sales executive who can assist them throughout the enrollment process.

The NJ-HITEC and HIMSS Latino partners are assisting in the recruitment of providers who practice within medically underserved areas for this program from their vast networks across New Jersey communities. These partners are working cooperatively with Emdeon to create a strategy that focuses upon identifying and recruiting providers within underserved communities who are willing to adopt EHRs, especially those interested in qualifying for federal incentive dollars.

How many practices do you anticipate being eligible, and how many do you expect will apply?
While we aren’t sure how many will apply, the HHS OMH recognized that the counties of Camden, Essex and Passaic have the largest percentage of underserved communities. Through our collaborative efforts with the OMH, HIMSS Latino and NJ HITEC, we hope to reach many of those physicians within those counties to take advantage of the 12-month program.

How will Emdeon and its partners determine if this program is a success?
Together with our partners, we believe success will be donating all 100 licenses to providers in underserved communities. The reporting element of this project will help OMH understand the progress of EHR adoption in the context of how long implementation takes in its entirety.

So it seems that Emdeon and its partners certainly have their ducks in a row when it comes to aiding and abetting these physicians before, during and even after the program is technically over. I’ll be interested to see if this model will, in fact, be successful, and if it can be supported in other underserved areas across the nation.

For more information on participating in the program, check out: http://www.emdeon.com/newjersey/

I’ve had the good fortune in the past year or two to watch one of my daughters’ favorite babysitters blossom into a full-time nursing student at the University of West Georgia. Not only do my girls benefit from her great bedside manner, including an infinite amount of patience, but I get an occasional inside glimpse into the world of digital medical record keeping in the greater Atlanta area.

Her training at West Georgia has taken her to Children’s Healthcare of Atlanta – Egleston, Wellstar Cobb and Austell, Fayette Piedmont, Tanner Medical Center and Gentiva Healthfield Hospice. She graciously offered to share her rookie’s perspective on the electronic medical records – including SCM/Quest (Allscripts Sunrise Clinical EHR system) and Meditech – she has used at several of the facilities she has trained in.

How long have your healthcare training facilities had EMRs in place?
All except Gentiva Healthfield Hospice – in-home hospice care, for the most part, sticks with paper charting. If they were to make the switch to an EMR, they would have to have access to a central database from their personal computers/iPads/Blackberries, etc. All others have had some sort of electronic database for at least five years.

How intuitive did you find them to be in your first training sessions/rounds?
Once I had been trained in the first system I encountered, the rest seemed very user-friendly. They have been in use long enough now that they are efficient and fairly self-explanatory.

They all allow an employee to cluster patient care and spend enough time with the patient because the time stamp on documentation can be changed to the time that the intervention was completed. For example, I could complete a full assessment on a patient, bathe them and administer their medications without having to document in the computer every few minutes. I could just open their EMR after completing their care and add the correct time stamp on my documentation.

What were the easiest to use, and what were the most difficult?
Meditech was the most difficult to use, perhaps because I had limited access as a student. It was difficult to find complete admission notes and patient histories.

Speaking from a “rookie’s” perspective, what would you tell vendors of these systems to better their products?
Add a patient verification requirement before each documentation session, i.e. each set of vital signs, medications given, etc. (Something simple, like a box with the patient’s name and DOB and an “Ok” button)

Did your supervisors express any enthusiasm or dissatisfaction with any particular systems?
All expressed enthusiasm, but they also were concerned any time a system was to be updated with even minor changes. Fayette Piedmont uses one EMR system for Labor and Delivery, and a completely different system for the rest of the hospital. This means, for the staff, that a new baby’s records have to be re-entered into a new system once they are discharged from labor and delivery and admitted to the NICU or postpartum unit. It also means the pharmacy has difficulty accessing vital information when, for instance, they need to know a baby’s weight to send the appropriate dose of medication to the NICU.

How aware are you of post-implementation training that goes on with EMRs, based on the facilities you’ve trained at? Do your supervisors ever mention it?
Once an employee is hired, they usually must display proficiency with the charting system within a specified training period. When Fayette Piedmont updated SCM/Quest, they did not retrain each employee, but they did send out a packet with a detailed description of the changes. From what I have seen, the older nurses who may have preferred paper charting at one point do not seem to have any problems with the electronic charting.

Have you been made aware of any increase/decrease in positive clinical outcomes as a result of physicians/nurses using these systems? Any examples you feel comfortable sharing?
The major changes to these systems each time they are updated usually involve the addition of safeguards. For example, the newest version of SCM/Quest has the patient’s name, weight, room number and allergies on every page of the charting system, and in multiple locations on the page.

For the employees who pay attention, this has reduced many documentation errors. There is also an embedded link to drug guides in every electronic medication order with explicit instructions and safe dose ranges. For the employee who knows these features are there, they are a tremendous help, and they do serve to protect the patient. It is still possible to document in the wrong patient’s chart, without realizing it, in any system.

Needless to say, it will be interesting to see how her experience with EMRs changes as she continues her studies and then moves into the professional world of nursing, which will likely coincide with healthcare facilities continuing to move through the various stages of Meaningful Use.

Stay tuned for next week’s post, in which I’ll profile an EMR educator, and find out what other students are facing when it comes to EMR training. In the meantime, what sort of healthcare IT-related challenges will our new workforce face in the coming year? Please share your thoughts in the comments below.

One of the things I’ve heard doctors say over and over and over again is:

Did this EHR vendor consult doctors?

I must admit that it’s kind of ironic statement to me. Mostly because the straight forward answer is really easy, but that answer misses what the doctor is really saying.

The Easy Answer
Yes! Every single EHR vendor has consulted a doctor. Every one of them has doctors on staff, on an advisory board, testing their EHR software, using their EHR software, and most have all of the above. They have boards of doctors involved in the development. They have advisory boards. Every EMR works and consults with doctors in creating their product.

The Real Message
What the doctor is really trying to say when they say this is: This EMR software doesn’t have the workflow that I and my doctor friends use or This EMR software doesn’t work the way that I think it should work.

The problem with all of this is that I can’t say I’ve ever seen two doctors work the same way. So, pretty much every doctor is going to have some issue with every EHR software. Plus, even if you consult a doctor, that doesn’t necessarily mean that the doctors working for the EHR are: 1. Great at making EHR software 2. Representative of the general doctor population 3. Good at abstracting workflow so it can work across various doctors 4. etc.

Considering the number of people who’ve said the above statement, obviously some doctors (the ones many EHR vendors consulted) aren’t good at a number of those things. So, maybe we should change the question to: “Did this EHR vendor consult the right doctors?”

This morning, I read about a case that engaged me on many, many levels. On the Health Care Renewal blog, blogger InformaticsMD has a fascinating post on a medical malpractice and how EMRs allow this to happen. Here are the key points noted by the blogger:

• Samuel Sweet, a health 62 year old, was admitted to University of Pittsburgh Medical Center (UPMC) with a headache. It turned out to be a treatable amount of bleeding in the brain. He died three days after he was admitted, on May 16, 2009, much to the surprise of his family with whom he had been conversing only six hours earlier.

• Apparently, Mr. Sweet had been intubated. His breathing tubes were removed on the day of his death, and it was soon apparent that he could not breathe on his own. Doctors tried to intubate him again, but could not do so, and this resulted in his death.

• At UPMC, difficult intubations cases must be flagged as such in the EMR. The patient’s record from the EMR then displays a bright yellow banner on top, noting the intubation problems. This is done so that when physicians change, the attending physician is alerted to the problem, and consults with prior notes in order to fix the problem. “Difficult intubation” was not noted in Mr. Sweet’s record.

• A civil case against UPMC was filed by Mr. Sweet’s family. Some detective work later, their defense team alleges that a full three days after Mr. Sweet’s death, after a post-mortem meeting, Dr. Simmons, a QA official from UPMC “accessed” the UPMC EMR system, and apparently entered data stating that Mr. Sweet was a patient with difficult intubation. The defense has audit trail evidence from the EMR to back their claims. They further allege that when that action failed to post-facto flag his existing records with yellow warning banner, Dr. Simmons tried to retract the “diff intub” entry, and unfortunately for him, even that cancellation of status was logged.

While I am fascinated by InformaticsMD’s write-up, I don’t fully agree with the apparent conclusion reached – namely that “EMR’s can detract from a clear narrative, and facilitate spoliation and obfuscation of evidence presented.”

I would argue to the contrary – that because there is an EMR, there is even an audit trail possible. And rather than facilitating “spoliation and obfuscation of evidence”, the EMR audit trail has shown up whatever tampering was involved. If UPMC simply had a paper based system, think about how much easier it would be to create paper records on official stationery, without date/time stamps I may add, post-facto.

EMRs can also be designed to meet certain additional needs – for example, a lock-down feature that locks down patient records from editing once a patient is flagged as deceased. There is no real counterpart for such a feature in the paper records world. Other lessons learned: If you’re springing for an EMR, it makes sense to know what metadata is being logged, and how you can access them – a pickle Dr. Simmons would have clearly avoided had he been IT savvy enough.

But a word to the wise: even an audit trail isn’t fool-proof. And if you’re in the market for an EMR, here’s a key difference between a “free” EMR somewhere on the cloud, or a pricier product on your own servers, administered by a savvy IT administrator on your payroll. Who administers the data makes a huge difference – if you own the database and your IT administrator has access to the database itself, you *can* manipulate any audit records generated from the EMR front end. Conversely, you must research what your vendor administered EMR is doing with your data, and what checks the vendor has on its IT staff.

Read more about the Sweet case on the Health Care Renewal blog.

I was talking to a physician friend during the week, and getting his take on EMR implementation. He would dearly like to implement an EMR in his practice. However, the major roadblocks he’s experiencing are in terms of costs. The quotes he has received for EMR implementation runs close to 80K. If he bills patients 500K a year, if he does not implement an EMR solution at all, the differential on the Medicare rebates in the first year would be 1 percent of $500,000, which is $5000, which is a number he says he can live with. If he implements an EMR, his two physician practi ce stands to make $88,000 from Medicare (they don’t see many Medicaid patients). In other words, if he spends 80K for his practice, or shells out 40K personally, he stands to gain $44,000. If on the other hand, he maintains status quo, he loses just $5000. Given the pain of choosing an EMR and EMR implementation, he’s probably better off doing nothing, he believes. And let’s not forget, it’ll be live people working with an EMR system, and productivity will actually take a hit before rising slowly back to pre-EMR levels, as this Feb post by Robert Rowley on Practice Fusion’s blog shows.

In other words, there are monetary incentives but sometimes just don’t make real-world sense.

This same math would look a lot different in a multi-physician practice. The same EMR implementation cost would be spread over a larger base, and more of the incentive money would actually reach the physician.

Which brings us to Practice Fusion. On this blog and elsewhere, Practice Fusion has got a lot of press (Full Disclosure: Practice Fusion is an advertiser on this site), not all of it positive.  Not being a medical practitioner, and never having used any EMR personally, my idea of how Practice Fusion stacks up functionally against other EMRs is pretty much second-hand info gleaned from reviews (John had a recent post on Black Book rankings. It’s interesting to me that Practice Fusion shows up in only the 1-Physician Practice rankings among the top 20.) There are those that caution the model of free. There’s also some debate whether a one-size-fits-all approach will benefit every kind of practice. But just based on its economic model, Practice Fusion is a system I would at least recommend my friend look into.

As you know, I regularly like to highlight some of the best and most interesting comments on my various websites. Especially since I know many of you don’t read all the comments (shame on you). This comment on meaningful use comes from someone who identifies themselves as SoftwareDev and works for an EMR vendor:

Coincidentally, I actually came up with the exact same conclusion [see original post] when reviewing the specs the other day. What I mean is, I identified that the way that we track “problems” in our software serves our customers well, but doesn’t really meet the measurement method of Meaningful Use.

In my app, I can record a “problem” using an ICD-9 code on the patient record (chronic) as well as on the visit (acute/episodic, based on Dx attached to the charges posted for that encounter). I also track descriptive (non-standardized) phrases in our Medical History. The former is good because it meets the standardized terminology requirement, but it fails because I don’t keep a “history” of active, or inactive problems. The latter is good because it is more “all encompassing”, including problems that the patient isn’t actually being seen by this particular doctor for, but also fails because it isn’t recorded by ICD-9 code and descriptor.

Either way, I have to revise the software’s method of recording “problems”, both for historical purposes and for proper coding, and ONLY to meet the Meaningful Use requirement. Not a single customer has ever voiced a request remotely like this to me in my 12 years of handling software in this sector.

Descriptions like this is why I’m concerned about the impact of meaningful use. There’s little doubt that the EHR incentive money has stimulated interest and even purchasing of EMR software. I just wonder what unintended consequences will come from meaningful use and EHR certification. Sadly, the above description may meet meaningful use, but doesn’t sound like meaningful patient care.

As we all know, few EMRs are a breeze to use.  In fact, many have such awkward, counterintuitive UIs that they ought to be thrown back into the pond.

On the other hand, superstar consumer apps like Facebook and Amazon have hooked people by the millions with intuitive, logical interface designs that simply addict users.  (And let’s not forget Apple, whose gift for consumer design has vaulted it from has-been to trend setter for the world.)

One CIO, Dale Sanders of the Cayman Island Health Authority, has taken these  examples and run with them, making what seems like a very strong argument in favor of the these giants’ approach:

In Facebook, we have a perfect framework for longitudinal documentation, collaboration, messaging, and scheduling between a patient and members of their entire care team, including family and friends.

We also have a framework for easily integrating data from other sources to enhance the value to the patient’s healthcare – there’s no equivalent of HL7 interchange going on in Facebook.  It references data located in other sources and systems. Can you imagine Facebook surviving if it required itself to house all the data that it presents?  Facebook takes great advantage of referencing and pointing to data in the source systems.

In Amazon, we have a perfect and familiar metaphor for ordering tests and procedures; tracking them; assessing their costs; rating them and seeing how other clinicians rated those orderables and referrals; and adjusting orders based on the behaviors and ratings of other clinicians, etc.

What makes his thoughts more interesting is that he actually marks up screenshots of key Amazon and Facebook pages, commenting directly on aspects he thinks EMR vendors could adopt.  It’s a thought-provoking exercise:  I recommend you check it out.

As we noted in a previous post, the latest group of EMR buyers have gotten savvy about support.  As a new study suggests, more than ever, providers are choosing vendors who offer a great deal of handholding.  And that’s probably a good idea, according to Michael Patmas of the American College of Healthcare Executives.  Below,  here’s some of his thoughts on EMR and CPOE project failures.

I have had the unfortunate experience of being in two organizations that had EMR and / or CPOE implementation failures as well as one organization that was successful. A key learning for me was the need to adequately fund training and support. Too often, implementation plans are driven by the vendor who tend to under emphasize the training needs. Simply providing a few hours of hands on training for the physicians is not enough. The real training begins after one flips the switch and providers have to actually work with the system in real time during clinical encounters. That’s when having trainers available to sit with and coach the providers is essential. In every implementation failure I have seen, the organizations under-invested in training and ongoing support.

Sadly, though, many providers seem to cross  their fingers and hope a little training will somehow diffuse automatically into the organization.  This is a dangerously irresponsible stance, but it’s all too common.

In fact,  at three separate community hospitals, I’ve personally witnessed doctors and nurses huddled together over an EMR workstation trying to teach each other how to use the system.  If it made me squirm — under these circumstances, serious  errors like misdocumenting drug allergies are all but inevitable — hospital leaders should be terrified, shouldn’t they?