Welcome to EMR and EHR

I always like it when people ask me questions about EMR. That way, I know that I’ll be providing at least some value to someone. Brian asked the following question in the comments:
Do you know who actually makes the decisions to purchase EMRs? For example, at large hospitals or medical groups, is it CIOs, and in small practices is it physicians?

This is a really hard question to answer. In fact, it’s likely one of the reasons why making the EMR sale is pretty hard. Each organization is very different. I guess this is a byproduct of the capitalist society that we live in.

That said, in hospitals, it usually is the CIO that is making the final decision to purchase an EMR after the CEO’s approval of course. Although, many times the work of selecting the EMR software and going through the EMR review process is delegated to a committee of people in the hospital organization.

The medical groups are harder to analyze since they come in all shapes and sizes. Not to mention varying governance structures. I would likely define these practices in two categories: physician run groups and manager run groups. You can guess who makes the decisions in these two categories. With that said, the doctors can really make an EMR implementation miserable if they’re not on board with the EMR selection. So, even if the practice is not physician run, you better consider these doctors in the process.

Small groups are generally more heavily influenced by the physician’s choices. Occasionally you’ll come across a strong practice manager, but usually that person is strong because they know how to work well with the doctor and their needs.

Certainly there a lot of other variations, but this is generally what I’ve seen.

In my post about an EHR stimulus calculator on EMR and HIPAA, a user left an interesting comment that I thought might start some discussion:

Does the calculator account for the 30% loss in productivity that is essentially universal when a group adopts EMR? Most highly productive groups would be better off rejecting the stimulus, especially given the available crop of clickorrhea that passes for an EMR.

HISTalk had this insightful point:

From Day Tripper: “Re: ambulatory EMR vendors. I asked several EMR vendors if they have seen a big increase in buyers, especially now that we at least have the interim final use definitions. The general consensus is that many physicians are still dragging their feet.” I’ve heard that comment as well. Either because of fear or because it sounds like a good excuse, many physicians are waiting until the MU guidelines are truly final and the certifying entities are identified. Perhaps a minority of physicians are savvy to understand that the RECs will offer some free implementation services so they are waiting for those to ramp up. And, likely others are waiting to see what opportunities their hospitals may offer to affiliated physicians. In other words, if you are looking for an excuse to not move forward, there are plenty to choose from.

I ask a number of EMR vendors the same question. A few had seen some increase, but for the most part they were all still waiting. I think Inga’s comment that there being plenty of excuses to not implement is true. This is unfortunate, since before the EMR stimulus most of the excuses had played themselves out and nearly disappeared. It seems that the EMR stimulus offered up a new set.

I will say that I’m not so sure how much “free” help the RECs will end up giving. I really wonder what most of them are going to do. One of my projects since HIMSS is to make contact with a number of the RECs.

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.

So many people have propped up the VA’s EMR system (Vista) as the model for how EMR should be done.  This story about the GAO finding the EMR implementation over budget is really interesting.  Here’s just one short section about the budget that they have for the VA EMR:

VA officials cited resource availability and interdependencies among projects as key drivers of cost and schedule variances. The GAO has estimated that the program will overrun its current budget – worth approximately $1.897 billion – by $350.2 million.

WOW! That’s a lot of money. I would hope that if you’re spending close to $2 billion you’d have something good to show for it. Too bad it’s just not reasonable for most doctors offices to spend that kind of money.

Here’s another interesting quote from the article (emphasis added):

VistA-FM is designed to provide a framework as well as additional standardization and common services components. It’s also intended to eliminate redundancies in coding and support interoperability among applications. However, VA officials have told the GAO that VistA-FM is costly and difficult to maintain and doesn’t integrate well with newer software packages.

I’m sure the MUMPS fans will come out of the wood work and tell us how great it is. I’m sure it does some things very well. However, I agree with the quote from this article is that it doesn’t integrate well with newer software packages. This is a major problem if we’re talking about inter operable EMR software.

Vista is free for doctors offices. I think it’s the “difficult to maintain” issue that kills most people even with the free price tag. Of course, my focus is on ambulatory EMR. The hospital environment is a mess regardless of which EMR you choose.

This is a SHOUT OUT to all doctors who use EMRs. Which EMRs do you use and how do you like them. Do you love them or hate them? Are you luke warm in your like or dislike? Tell us which EMR you have and how you feel about it. Also tell us what you would do (the mistakes and the good moves) if you were looking into getting an EMR at this time.

I have personally looked at Greenway PrimeSuite, SOAPware, SRSsoft, e-MDs, AmazingCharts, NextGen, Centricity and others.

Can you comment on the cost and the usability?. Let’s share information so we can help other doctors choose systems that are usable, simple to learn, effective and efficient.

If you don’t have an EMR and are looking into one, what questions would you have for those “who have gone before you”? What advice would you be interested in receiving?

Hospitals are buying EMR systems for the Physician Groups that they own and they are allowed to pay 85% of the software and training costs for their independent physicians (physicians that they do not employ, but who refer patients to their hospital).

They are doing this for a number of reasons. It will improve communication for better and more efficient care and it will “connect” these physicians to that hospital (in multiple ways). Keeping the referral pipeline flowing is very important to hospital systems. This type of arrangement makes it more difficult for doctors to move their patients to other hospital systems and it builds loyalty.

Most hospitals are picking ONE system for their employed physicians and then they are going to offer to pay 85% IF independent physicians use this ONE system.

Although well intentioned (hospitals are trying hard to pick the best system for their doctors), I believe this approach is doomed to fail and will cause hard feelings and other problems.

Hospitals want all their doctors on one EMR system because of volume discounts and because they believe in maximal connectivity. Again, their intentions are logical and well-founded, but miss the mark.

Why will it fail? Because different doctors and different physician groups have different needs, different styles and different preferences. Doctors also need to be “masters of their own fate”, if they fail, they need to “own” the problem. In addition, hospital systems are only considering EMRs from the “big EMR companies” because they believe that “connectivity” trumps “usability”. When you limit your options to the “big EMR companies” you are choosing some of the least usable systems on the market.

Doctors need choice! They need to make the final decision on the system they purchase. Only they can find the best system for their practice and their practice style. One size does not fit all.

When the doctors become unhappy with the EMR software that their hospital chose for them (not usable, difficult to learn, decreases their productivity), they are going to become unhappy with that hospital system and their administrators. Since failure to implement EMR software is very high, we know this is going to happen not uncommonly. I anticipate lots of problems a few years from now. Let’s see how this plays out.

I am hoping that hospital administrators are smart enough to stay out of this EMR software trap. Give doctors a choice. Give doctors options. Don’t believe the big EMR company salespeople who tell you that you all need to be on the same system.

One Hundred Percent of Doctors and their offices use Practice Management Systems (PMS). Only 3% user “fully functional” EMR Systems. Why only 3% with EMRs and 100% with PM Systems?

The government is going to pay us $44,000 per doctor to use an EMR. They are going to give us a 2% Medicare bonus and other pay-for-performance incentives and they are going to penalize us in the future if we don’t use EMRs. In addition, hospitals are allowed to pay 85% of the cost of the software and training. Will all this money get us the use EMR? Can we be bought? Is it in our interest to use EMRs?

The CEO of SRSsoft tells us that this type of money is not significant if the EMR makes you less productive and less efficient. For example, if you bill $500,000 per year and your EMR makes you 10% less efficient, you lose $50,000 per year!

I agree with this CEO. We (doctors) will not embrace EMR systems until they are usable and they add value! “Usability is the effectiveness, efficiency, and satisfaction with which the intended users can achieve their tasks in the intended context of product use.” This definition comes from NIST, ISO and UserCentricity. Adding value means that it makes our jobs more enjoyable, shortens our work day or helps us provide better care.

Doctors use practice management systems because they are usable and they add value. Doctors do not use EMR Systems because most DO NOT add value and they are not usable. There are so many bad EMR systems on the market that the stench and confusion has caused many doctors to not even look (they ask their colleagues who have EMRs and these colleagues say “stay away, it is not worth the cost, aggravation and problems”).

I believe that there are some very good EMRs on the market. The challenge is to find them and promote them. If we (doctors) can find the good EMRs, word will spread and implementation will happen very rapidly!

We keep hearing about the Big National Data Bank for Healthcare Information. The thought is that you need a big data bank so everyone’s health information is available anywhere/anytime. This type of personal health information repository has many problems. First it is complex and expensive to set up and maintain. Second there are very significant and well-founded privacy concerns. And finally, this large, complex electronic structure may not be needed … it might even be counterproductive!

Is there another way to transport patient health data from one platform to another (so it can go from one EMR to another), so that healthcare providers, anywhere/anytime can provide fully informed care for individual patients which would be less expensive and higher in quality?

I think the answer is YES!

There are standard data exchange platforms currently being used which can help us all share “meaningful” personal health information. They are called the Continuity of Care Record (CCR), CCD and HL7. For more information on these platforms, I suggest you read Brian Klepper’s blog post. This blog gave me great insight into this connectivity issue.

In addition to obviating the need for a big data bank, these data exchange platforms make it possible for small, innovative EMR companies to compete and survive in the “EMR Jungle”. By allowing for diversity and encouraging innovation, we will end up with better EMR software. In addition, physicians will be able to pick EMRs that suit their practice style and can make them more efficient, productive and better doctors. I think we need a patchwork quilt of unique EMRs that are all well connected rather than a few big standard lemming EMRs that are totally connected by “big brother” or “big business”.

What are your thoughts on this topic?

We’re always happy to welcome people interested in doing quality guest posts on this blog.  So, when I got this in my email, I thought it was an important subject to cover on this blog.  The following guest post looks at some of the advantages of an EMR system.  This is a good start for those looking at an EMR system.  I think there are a number of other advantages that aren’t listed below.  I’d love to hear about other advantages of an EMR system in the comments.

The Advantages of EMR Systems

There’s talk of every public hospital in the USA being equipped with electronic medical record systems in a year or two; that’s how popular and necessary these information technology systems have become. And why not, considering the various advantages they hold. EMR systems:

• Lower costs in the long term: While the initial cost may be high, over a period of time, the average cost of the system becomes much less than a similar manual system. When records are maintained electronically, there is less room for error. Security is also enhanced leading to patient confidentiality and privacy.
• Eliminate repetitive and unnecessary testing: EMR systems help prevent repetitive testing and thus save both patients and hospitals a lot of money. They can be transferred via email to any hospital or medical practitioner in an instant thus avoiding the need for tests that have already been performed.
• Provide accurate medical information: Information that’s stored in the electronic format is not prone to human error and can be retrieved easily at the touch of a button or the click of a mouse. Search and retrieval times are a fraction of what they would be in manual systems.
• Allow information to be available anytime, anywhere: Doctors and other medical personnel can access medical records from anywhere using handheld devices like the iPhone and related software. This allows them to continue treatment no matter where they are and also to pass on information so that other physicians can also provide emergency care when needed.
• Allow for streamlined information: The information is stored in such a way so that retrieval of select data based on certain criteria and filters can be accessed. Besides this, physicians can also use the system to prescribe medicines for their patients from pharmacies that are part of the program. This allows patients to get refills directly without having to go to the doctor or the pharmacist. EMR systems also allow physicians to order diagnostic tests and view the results online.

This article is written by Kat Sanders, who regularly blogs on the topic of phlebotomist school at her blog Health Zone Blog. She welcomes your comments and questions at her email address:katsanders25@gmail.com.