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Breaking up with Your EMR is Hard to Do

In light of this week’s “holiday,” I thought I’d take a look at the current love/hate relationship the healthcare industry seems to have with electronic medical records and Meaningful Use.

Thanks are due to @mdrache and @EHRworkflow for their inspiration for the title of this week’s post:

The nay sayers seem to have become especially vocal lately, which may be due in large part to the passing of time. Those that have implementations under their belt now feel qualified to talk about the efficacy of the solutions they selected. Negative EMR press may also have bubbled up to the service in light of the recent RAND report, which backpedaled on previous predictions of cost-savings associated with healthcare IT adoption. That study broke the ice, so to speak, and perhaps made providers more comfortable with voicing their discontent.

In any case, if current healthcare IT press is any indication, EMR technology currently on the market has often left providers dissatisfied for a number of reasons. No doubt this dissatisfaction will be a subject of many show-floor conversations at HIMSS in a few weeks. I wonder how EMR vendors are preparing their responses. What will be their top three talking points when it comes to EMR benefits? It seems Meaningful Use incentives have lost their luster, and in fact have left many providers disenchanted with healthcare IT in general.

John Lynn posted a very telling reader comment over at EMRandHIPAA.com from a provider who used his Meaningful Use malaise to create a new independent practice business model. Is this an indication that more providers may “revolt” against Meaningful Use and the trend towards hospital employment? If so, what will the private practice landscape look like in three to five years?

Just how easy is it for providers to truly “break up” with their EMRs? We’ve all read the multi-million-dollar rip-and-replace horror stories – talk about a bad breakup. And then there are the providers that stay in dysfunctional relationships with their EMRs because they can’t afford a new one, instead developing copious amounts of workarounds potentially at the expense of clinical care and accurate reimbursement.

As of last summer, KLAS reported that a whopping 50% of providers were looking to replace their ambulatory EMRs, compared to 30% in 2011. A recent Health Data Management webinar noted more than 30% of ALL new EMR purchases are made to replace an existing EMR.

To me, these numbers beg a number of questions. Were first- and perhaps even second-generation EMRs just not mature enough for providers’ needs? Did providers simply not do enough due diligence before making their purchases? Will these impending replacement EMR purchases stick? If you have updated EMR breakup statistics or a crystal ball, please send them my way.

11 Reasons Why Healthcare is So Screwed Up

If you don’t read the GetReferralMD blog, you should go and check it out now. It is always chock full of strong opinions and thoughts on healthcare that will make you take a step back and consider what’s really going on in healthcare. This post I found on the 11 Reasons Healthcare is Messed Up is a good example. Here is the list of 11 reasons for those that don’t want to go read the full post:

1. Insurance Companies
2. Excessive Regulation
3. Shortage of Doctors
4. Medical Advances
5. Paper
6. Ignorance
7. Choice to Die
8. McDonalds
9. Cluster $#@! Of EMR’s
10. Healthcare Vs. Military
11. Pharmaceutical Companies

Of course, you should click over and read the full post. It’s chock full of commentary and explanation for each post. He basically brings out the big guns and says what a lot of people don’t say about healthcare. I don’t necessarily agree with all of them, but he does provide something interesting to chew on. Although, I do particularly like his call out of paper and the fax machines that continue to print out that paper at an extraordinary rate in healthcare.

As an entrepreneur, I also look at this list and think that it’s the perfect time for some companies to come and disrupt the current model. Any time there is pain in a system, there is also opportunity to relieve that pain.

Christmas Scavenger Hunt Inspires EMR Wish List

Happy holidays, dear readers! I hope my latest blog post finds you well, resting comfortably away from your usual place of employment, and not tied to a device despite being “on vacation” or attempting to take “time off.”

My family and I are a bit further South than usual, visiting family in Jacksonville and engaging in a time-honored tradition in nearby St. Augustine – the Holly Jolly Trolley. Never was there a better excuse to turn Christmas lights into a 3-D psychedelic experience.

We turned our annual light-seeing drive through the Blackhawk Bluff neighborhood into a Christmas lights scavenger hunt, checking off images from our list as we came across them during our drive. Suitable for the younger crowd, our checklist had images of traditional holiday décor – snowmen, stars, candy canes, candles, etc. The gingerbread man gave us the most trouble, and eventually we had to settle for seeing a gingerbread man windsock.

Driving home I got to thinking about what a similar hunt would look like, say, at HIMSS next year. Gather a group of providers, give them a list of EMR attributes and set them loose in the exhibit hall to find as many as possible within a certain amount of time. I wonder how many vendors/booths they’d have to stop at before they checked everything off the list.

For that matter, it would be interesting to turn the check list into a wish list – pinpoint a number of features providers most want in their EMR and see which vendor offers the most in one package. This would then of course lead to a comparison of price and customer reviews, but that’s another blog entirely.

What would such a check list / wish list look like? Based on the major healthcare trends that have come to light over the last year, I’m willing to bet these features (however pie-in-the-sky they might be) would be included:

Guaranteed security / protection, especially with regard to mobile EMR applications
Innate knowledge of ICD-9 to ICD-10 code translation
Ability to connect to any HIE at the click of a button
CPOE
Pop-up that suggests, on a patient-by-patient basis, how best to digitally engage with that particular person based on their preferred method of communication
Suggested protocols culled from evidence-based medicine analytics

What other features would likely be included? What vendors already offer a majority of these features? Do they exist, or will tomorrow’s start up be next year’s true game changer when it comes to success in the EMR marketplace? Please share your thoughts in the comments below.

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December 27, 2012 I Written By Jennifer Dennard

Filed Under: EMR EMR Technology Healthcare

Tags:Electronic Medical Record EMR Software EMR Vendor EMR Vendors EMR Wish List HIE HIMSS HIMSS 13 LinkedIn

EMRs Investors Stuck In Old Patterns

Today I read an intriguing piece in The New York Times which looked at different ways capital can be invested, and how over-reliance on one style may be cramping our economy.

In the piece, Harvard professor Clayton Christensen asserts that there are three main models for investing in innovation:

Empowering: These innovations “transform complicated and costly available to a few into simpler, cheaper products available to many,” Christensen says. Obviously, the reduction of the mainframe into consumer desktops is one example. These products open up new markets.

Sustaining: These innovations replace old products with newer ones that improve on the old (his example: The Toyota Prius hybrid). They don’t necessarily open new markets, as people often buy the improved model instead of the previous version, but they do keep the market moving.

Efficiency: These innovations reduce the cost of making and distributing products and services, making capital available to keep the improvement process. They generally don’t expand markets at all.

In Christensen’s model, industries cycle through each of these stages and create new markets and jobs in the process. But that engine seems to be stuck in neutral of late, he suggests.

At this point, he argues, VCs and companies with excess cash are focused on a new finance model which discourages investment in brand new, empowering innovations. Capitalists want to make big money but are being channeling into spending only on the third stage of the cycle.

So, why all of this economic analysis in an EMR publication? Well, because I’d argue that the EMR business has already fallen into just such a stall. Rather than come up with paradigm-shifting innovations which really empower doctors, vendors are falling over themselves to create more efficient models of the same basic thing.

Not only is that bad for the health IT economy, it’s bad for end users, few of whom are rapturously happy with the basic EMR paradigm. It discourages innovations that are patient-facing — such as a fascinating three-dimensional avatar I just heard about which can be used as a PHR — since there’s little if any funding for such projects.

Worst of all, focusing on efficiency doesn’t inherently improve patient care either, something we’d hope would be the fundamental goal of any EMR.

Given the stakes involved, let’s hope investors decide that chasing efficiency by reworking old models isn’t the best way to keep the EMR business alive. Otherwise, we may stay bogged down for many years to come.

AT&T/IBM Deal Pushes Cloud Back into the Healthcare Spotlight

I remember 2010 as if it were yesterday. I was somewhat new to the healthcare industry, attending my first Healthcare IT Summit, and trying to make sense of all the buzzwords flying around as a result of the HITECH Act being passed the year before. Cloud computing was definitely a hot topic – one that seems to have stood the test of time in the intervening years. Granted, I think its popularity has been somewhat superceded by phrases like mobile health, accountable care, patient engagement and electronic medical records (of course) over the last 18 months, but a recent flurry of cloud-related headlines may forecast a resurgence.

A report released earlier this year from MarketsandMarkets predicts that conditions are ripe for cloud computing to grow at an annual rate of 20.5 percent from this 2012 to 2017. (Bloomberg Businessweek puts the current market for cloud services at $14 billion.) The forecast makes a lot of sense when you look at it from the healthcare angle of Meaningful Use and EMRs. Providers, despite a few legislators’ recent objections, will likely continue to implement and attest during the next few years, leaving healthcare IT vendors – including those who put their EHRs in the cloud (Allscripts, NextGen and athenahealth are just a few that come to mind) – with no shortage of business opportunity.

And there are even more vendors behind those – the infrastructure folks like Verizon (See their recently announced HIPAA compliant cloud service) and Dell that provide the cloud’s backbone, so to speak. You may by now have seen headlines announcing that AT&T has partnered with IBM to offer a new model whereby “IBM … will provide the data-storage facilities and services, and AT&T will … offer the global network that clients will use to retrieve the data,” according to the Bloomberg write up. It is the closest relationship IBM has ever had with a phone carrier.

Undoubtedly, this new model will be tapped for healthcare purposes, but it’s still speculation as to just how it will be adopted for secure exchange of patient health information. I sent out a few feelers via my social networks to see if anyone related to either IBM or AT&T could provide more detail, and got back this statement from an IBM representative: “I would assume that there will be a HIPAA compliant component. It goes without saying that the healthcare industry is a HUGE segment for IBM.”

“Huge” just might be an understatement, as IBM has stated it wants to attain $7 billion in cloud revenue by 2015. In today’s terms, that’s just one vendor making up the current market value for cloud services.

I’ll be interested to see how this plays out, especially as previously lower profile (at least in the healthcare space) technology companies like Dell and IBM, and companies like AT&T and Verizon that are more widely known in the consumer market, continue to make healthcare IT headlines.

How To Grill An EMR Vendor

Today I found a nice blog piece on how providers — largely medical practices, the blog’s core audience — can grill EMR vendors effectively prior to sinking their money into a product. I say “grill” because the questions will force vendors to put up or shut up on several levels, something a lot of non-techy doctors wouldn’t know how to do.

Here’s the five questions, courtesy of the EMR and EMR Insights blog (with a few comments on each):

* When did your company start operations, and can I have 2 references from each year you have been in business?

I don’t know about you, folks, but assuming older companies will produce better results involves some significant risks too. Sure, a high-flying venture-funded partner might go out of biz next week, and that would be pretty terrible. On the other hand, many companies grow less creative and less flexible over time, and take their customers for granted — even if it’s not part of a doofus big vendor’s lineup. What about: “Can I have five references for clients in my specialty?” and “Please sign this contract addendum which addresses how you’ll handle it if your product is discontinued or you close you doors.”

* How many developers are assigned to work on your core EHR product? Where do the developers reside?

I like the Q regarding the size of the development team, which can be make-or-break factor in keeping your product updated and bug-patched. But as for where the developers reside, again, that’s a toss-up. You could hire a vendor with a large but poorly-managed development team, or a small vendor whose team is overseas — but well-managed and effective nonetheless.

* How was your product and company ranked in the Best in KLAS Awards — Software & Services Report – December 2011, and the KLAS Ambulatory EMR Specialty Report 2012?

Interesting. In theory asking about rankings is a good idea, unless you don’t respect the people doing the ranking. (I know my colleague John Lynn isn’t a raving KLAS fan.) I suppose rankings like these can be a touchstone, but they probably shouldn’t be a primary factor in EMR investment decisions.

* Do you have a whitepaper that explains your interoperability platform?

Definitely a good question, but the answer is probably over the heads of many clinicians and office managers making the EMR call. If a medical practice has someone on staff who’s geeky, or an IT consultant is on your selection team, sure, get the whitepaper. Otherwise, I believe medical practices would do better simply studying the literature and asking for a thorough, plain-language presentation explaining these features.

* What are your specific plans for meeting all the Meaningful Use requirements of Stages 2 and 3?

What can I say but yes, yes and more yes. A company that can’t answer this question should be toast.

One final note. How about throwing in “If I can’t get to Meaningful Use within x days, do I get my money back?” Seeing how your vendor reacts should be, um, educational.

EHR Company Funding Risks – Large Company Backed EHR

This is the fifth and final post in my EHR Company Funding Risks series that was started in response to my original post about the The Current Health IT & EHR Bubble. In this series, we’re looking at the following EHR company categories: Seed Funded, Well Funded, Positive Cash Flow, Large EHR Company, and Large Company Backed EHR. Next up is Large Company Backed EHR.

Large Company Backed EHR
The companies in this category are quite interesting, because they can often exhibit the characteristics of EHR software in every other category of EHR company. It’s all about the story of the company. For example, I’ve come across some really large companies who have developed their own EHR and only have 1 practice using their EHR. This is very much like a seed company. There are some larger companies who have acquired essentially the EHR software of another company and now they’re trying to grow the user base similar to a well funded EHR company.

I can think of a few EHR acquisitions where the large EHR company acquired a cash flow positive EHR company and they’re continuing to grow that EHR company in a cash flow positive way. Then, of course there are a few large companies that have large EHR install bases as well. There’s also everything in between in this category, so it’s hard to generalize about this group.

With that said, since it has the backing of a large company (in healthcare or not in healthcare) the biggest risk is that they’ll shift their priorities from the EHR software and on to something else in their company. Most large companies trying to get into the EHR software business come quick out of the gate. If they do well, they’ll continue growing it like they did. If they don’t do well, they’ll often throw in the towel by cutting resources to that venture and then eventually a sale of the EHR assets to another company.

Read all the posts in the EHR Company Funding Risks series.

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June 1, 2012 I Written By John Lynn

Filed Under: EHR EHR Market Electronic Health Record Electronic Medical Record EMR Healthcare IT Healthcare IT Market

Tags:EHR Acquisition EHR Companies EHR Company Risks EHR Funding EHR Investment EHR Merger EHR Users EMR Acquisition EMR Company Risks EMR Funding EMR Investment EMR Merger EMR Vendors Large EHR Companies Large EMR Companies Publicly Traded EHR Companies

EHR Company Funding Risks – Large EHR Companies

This is the fourth post in my EHR Company Funding Risks series that was started in response to my original post about the The Current Health IT & EHR Bubble. In this series, we’re looking at the following EHR company categories: Seed Funded, Well Funded, Positive Cash Flow, Large EHR Company, and Large Company Backed EHR. Next up is Large EHR companies.

Large EHR Companies
Most of the EHR companies that fit into this category are publicly traded EHR companies (with a few notable exceptions). Each of these EHR companies has their own story, but the majority include some mix of EHR acquisition or EHR merger to get into or expand their EHR market reach. Often this means that the EHR company has more than one EHR software under their purview.

Many of the larger EHR group practices and particularly the multi specialty clinics look to the larger EHR companies because these large EHR companies have usually worked to try and cover every EHR specialty in their EHR. In most cases the EHR software has been around for a very long time. This is good because then the software is often mature, but it’s also bad because it’s often built on old technology.

The large complaint against these large EHR companies is that they’re large and impersonal. That they are out of touch with the customer. Of course, this is kind of the nature of being a large company and having a large user base. Plus, you can imagine the challenge listening across a half dozen different EHR software products.

The risks associated with these large EHR companies software usually has much less to do with cash flow and much more to do with the decisions of the EHR company executives. With multiple EHR software under their umbrella, will they choose to close the one you use down and focus on their other EHR products? Will your EHR product get lost in the corporate shuffle of priorities? Sure, they’ll still support your EHR product if there’s an issue, but have they dedicated the company resources to your EHR or to another product in the company’s portfolio?

One argument that larger EHR vendors have made is that they’re the only companies that have the resources available to create the EHR software of the future. Some argue that many of the smaller EHR companies won’t be able to meet meaningful use stage 3, because they don’t have the resources available to do that. Not to mention when we eventually have to do Watson like Smart EHR software integrations across large data sets. I think the first part about doing MU is overstated. I think the jury is still out on how smart EHR software will become over time and how smart physicians require their EHR to be.

Next up, we’ll look at Large Company Backed EHR. Read all the posts in the EHR Company Funding Risks series.

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May 29, 2012 I Written By John Lynn

Filed Under: EHR EHR Market Electronic Health Record Electronic Medical Record EMR Healthcare IT Healthcare IT Market

Tags:EHR Acquisitions EHR Companies EHR Company Risks EHR Funding EHR Investment EHR Mergers EHR Users EMR Acquisitions EMR Company Risks EMR Funding EMR Investment EMR Mergers EMR Vendors Large EHR Companies Large EMR Companies Publicly Traded EHR Companies Smart EHR Smart EMR Watson

EHR Company Funding Risks – Positive Cash Flow EHR Companies

This is the third post in my EHR Company Funding Risks series that was started in response to my original post about the The Current Health IT & EHR Bubble. In this series, we’re looking at the following EHR company categories: Seed Funded, Well Funded, Positive Cash Flow, Large EHR Company, and Large Company Backed EHR. Next up is Cash Flow Positive EHR companies.

Positive Cash Flow EHR Companies
This type of EHR company is usually a conservatively funded EHR company (often through non traditional funding mechanisms, or through a private buy out) that have grown large enough that their current user base provides enough cash flow to cover the EHR company’s ongoing expenses. The majority of these EHR companies have been around for a long time. In most cases they started out as EHR only companies (since everyone already had a PM system) and over time were able to grow a large EHR user base.

Instead of going after a large funding round, these EHR companies stayed small and chose to grow slow and steady over time. At this point, most of these companies have a large enough user base and enough cash flow that they’re in it for the long haul. While a sale could happen, most are content to continue growing the way they’ve done for a long time.

The users of these systems are usually happy with the software. Plus, they’ve often been using it so long that the idea of switching is something they wouldn’t even entertain. Even if the EHR software has some issues, the practices know the problems and have found ways to work around them. Plus, I’ve heard from many about the kinship they have with the EHR software that they’ve had for so long.

The real question for these EHR companies is how well they’ll be able to retain their existing EHR user base and/or how well can they acquire new EHR users. At some point if they aren’t maintaining or growing their EHR user base, they won’t have the cash flow needed to continually improve the EHR system with changing technology and clinical requirements. Plus, considering the fast pace of technology, time and their legacy software creation starts to catch up with them.

Many of the best specialty specific EHR companies have been able to reach this category. Some are still in the seed funded or well funded categories, but most of the specialty specific EHR companies I’ve seen have reached the cash flow positive category or are really close to getting there. Most of them realized that they had a very specific EHR market and so they had to grow it slow, steady and focus on revenues early.

Next up, we’ll look at Large EHR Companies. Read all the posts in the EHR Company Funding Risks series.

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May 25, 2012 I Written By John Lynn

Filed Under: EHR EHR Market Electronic Health Record Electronic Medical Record EMR Healthcare IT Healthcare IT Market

Tags:EHR Companies EHR Company Risks EHR Funding EHR Investment EHR Users EMR Company Risks EMR Funding EMR Investment EMR Vendors Positive Cash Flow EHR Companies Positive Cash Flow EMR Companies Specialty EHR Companies Specialty EMR Companies

EHR Company Funding Risks – Well Funded EHR Companies

This is the second post in my EHR Company Funding Risks series that was started in response to my original post about the The Current Health IT & EHR Bubble. In this series, we’re looking at the following EHR company categories: Seed Funded, Well Funded, Positive Cash Flow, Large EHR Company, and Large Company Backed EHR. Next up is Well Funded EHR companies.

Well Funded EHR Companies
These EHR companies are those that have moved past the beta phase of their EHR and have usually gotten a large second round of funding that will allow them to work on scaling their EHR user base. This is where I see the largest number of what most would consider “startup” EHR companies. They usually have a few million in the bank and somewhere between 50-200 doctors on their platform.

With the money in the bank, most of these EHR companies have a number of years of runway to be able to see their EHR company play out. They still haven’t made it to what I call the EHR promise land of 1000+ doctors on their platform, but they have enough money to try and reach that goal over the next couple years.

The risk for a practice choosing one of these well funded EHR companies is what will the EHR vendor choose to do once they reach 1000+ doctors. Will they sell the company off to someone else (which almost never ends well for the practice)? Or do these EHR vendors have the staying power and desire to go after something much larger? The other risk is that the EHR company will only ever have a few hundred doctors. When you’re a well financed EHR company that doesn’t gain traction, this will usually end up in a fire sale of the EHR to some other company who wants to acquire the users you do have.

Despite the risks mentioned above, many really love these “startup” EHR companies that have plenty of funding. They’re usually very responsive companies that are able to have a real personal touch with their users. They usually have some unique selling proposition which the practice found so intriguing in the first place.

Most of the Free EHR vendors fit in this or the previous seed funded category as well. However, the amount of funding that the Free EHR vendors require is a multiple higher because they usually need to be able to reach a certain install base before their revenue model kicks in. The other principles are very much the same. Although, most of the free EHR vendor revenue models require a large user base. The Free EHR promise land is probably closer to 10,000 and some might argue that to really make it work they need 100,000+.

Next up, we’ll look at Positive Cash Flow EHR Companies. Read all the posts in the EHR Company Funding Risks series.

Breaking up with Your EMR is Hard to Do

11 Reasons Why Healthcare is So Screwed Up

Christmas Scavenger Hunt Inspires EMR Wish List

EMRs Investors Stuck In Old Patterns

AT&T/IBM Deal Pushes Cloud Back into the Healthcare Spotlight

How To Grill An EMR Vendor

EHR Company Funding Risks – Large Company Backed EHR

EHR Company Funding Risks – Large EHR Companies

EHR Company Funding Risks – Positive Cash Flow EHR Companies

EHR Company Funding Risks – Well Funded EHR Companies

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