The American Health Information Management Association’s (AHIMA’s) annual show is right around the corner. HIM professionals will gather in Salt Lake City next week for a few days of educational sessions, exhibits, networking opportunities and even off-site visits to local healthcare facilities such as Intermountain Medical Center and the University of Utah and Cancer Registry.

It will be my first time at an AHIMA show, and truth be told, I couldn’t be more pleased that I’ll get to see Salt Lake City in the Fall. I’ll of course be on the lookout for the latest and greatest healthcare IT, particularly those technologies related to electronic medical records (EMRs). I’m also hoping to chat with AHIMA’s new CEO, Lynne Thomas Gordon, about how AHIMA will be helping its members transition through healthcare reform in the near future. (Look for a wrap up in next week’s post.)

Most of my time will be spent on the show floor, learning about these new technologies and finding out what health information management challenges and solutions providers are dealing with. James Watanabe, Director of Healthcare Business Development at Perfect Search Corp. – a first-time exhibitor this year, recently shared with me his thoughts on what’s he’s expecting and hoping to get out of the event.

What health information management challenges are your customers currently facing?
JW: “At Perfect Search, our clients are typically utilizing our unique indexing and search technology to deal with the challenges associated with extreme data growth and complexity. One of the challenges in the industry is that in addition to the explosion of digital data, there seems to be no clear direction in terms of standardization and policy. Given this uncertainty, vendors must not only help facilitate compliance now, but be nimble enough to support changes in the future. We see Perfect Search as a core technology that can be utilized to help organizations deal with these challenges as they come, and believe that the implications for such a technology are truly deep and profound.”

How does your team plan on addressing these challenges at the AHIMA show?
“We will be demoing our deep data-mining tools and highlighting some of our key strategic partnerships that showcase how the technology is being utilized today. We are able to provide at least a 10x improvement in indexing and search speed, be much more comprehensive in terms of the data we search (structured EMR, unstructured clinical notes, lab data, DICOM radiology images, etc.), and operate on up to 90% less hardware. Using our solution, clients gain real time insight into their data to improve quality scores, help mitigate fraud, improve billing processes, better facilitate clinical trials, and any other deep data mining they might require.”

What does Perfect Search hope to get out of the show as a whole?
“Despite some key partnerships such as Dell, Fujitsu, CA and Nuance, Perfect Search is relatively unknown in the healthcare space. We intend to use AHIMA as a way to raise awareness of our unique technology, it’s many applications in healthcare, move business deals forward, and seek out new partnerships in the space.”

How does Perfect Search’s Medical Record Search technology integrate with providers’ interoperability efforts?
“Perfect Search is the only indexing and search technology that is able to deal with both structured EMR content and unstructured clinical notes data equally well, to produce true semantic search. There is currently a disconnect between what most EMR vendors are pushing and what physicians and other users are wanting. EMR vendors push structured data, and clinicians are interested in utilizing their existing business practices, which for many means producing and utilizing unstructured clinical notes data. We believe that the ability to connect to all critical data needs to be a component of any good EMR or health information exchange (HIE) solution and is something that we can provide today.”

Can this technology search or be integrated into EMRs or HIEs?
“Absolutely.”

It would also seem that this technology might be useful from a business intelligence perspective – a much-needed solution in terms of providers determining what healthcare IT systems might be right for their facility.
“Definitely. 80% of business intelligence reporting and analytics is connecting to data. In large pharma and research, the deep data-mining tool we have created enables users to create and run complex ad hoc queries in real time and without IT. This tool is the difference between getting data now versus 12 hours from now, tomorrow, next week, or even next month, which is standard for most companies of significant size.”

How do you see Perfect Search technology evolving to meet the needs of healthcare providers?
“The Perfect Search team continues to work with industry experts to build new applications around the technology and strengthen existing products. Ours is a unique technology that enables users to connect to critical data at least 10 times faster, be much more comprehensive in terms of the content we search, and operate on up to 90% less hardware. “

I’m looking forward to speaking with the Perfect Search folks from the show floor. Know of any other exhibitors I should check out? Salt Lake sites I should see? People I should bump into? Let me know in the comments below.

John’s Comment: Along with Jennifer, I’ll be at AHIMA as well. I’m definitely happy to meet with people at AHIMA also and enjoy attending the event for the first time.

Last week, I wrote about a conversation with a physician friend on the costs of moving to an EMR. That conversation segued into a discussion of free EMRs and how they can be a good thing for small (definitely a game changer for solo or two-practitioner) practices. This week, I’m analyzing free EMRs from the advertising angle. My friend made a comment during our discussion that gave me pause. He said he didn’t want advertisements distracting him when he was talking to a patient, he’d rather spring for a package that charged him a few dollars a month than one that had ads embedded inside it.

I think the ad question is pertinent to both sides of the equation. As a physician, I don’t want the 15 minutes I spend per patient cut down even more, because I want to get rid of those pesky pharmaceutical ads. As a patient, I don’t want to get the feeling that I’m the third wheel in the space between my doctor and his iPad.

And frankly, the low or no-cost, high volume Walmart strategy doesn’t make much sense to me in the long term. This is not based on some well-pedigreed consumer behavior study but what I’ve generally witnessed, or done myself. I’ve trained myself on the art of selective blocking. When I’m on Google, I studiously avoid looking at the highlighted links on the right, and top of the page. The same way, on eBay, when I’m looking for job opps, I generally skim past the purple highlighted vendors. If you’re a TV junkie, think about when you take your bathroom breaks.

In other words, we all have our own blocking strategies to ignore ads, which is probably not such good news for advertisers. This is not to say that advertisers won’t advertise, or vendors won’t make money.

If doctors already have some amount of natural reticence to ads, how are free EMR vendors going to make money? (I’m not sure if the ad model in free EMR packages is click/pageview driven, or a set price for simply being placed on the page, like magazine ads.) Free EMR vendors might then also offer ad-free versions, for additional dollars a month. At this point, they become just like other EMRs – i.e. when the costs are non-zero, price will not be the only differentiating factor when you’re judging EMR quality.

And yet, if my friend spends $100 a month for an ad-free EMR, as one vendor is offering, he’ll spend only $1200 a year personally for EMR, and be able to avail his Medicare 44K, as opposed to the 80K-100K EMR bids he’s currently getting. Even when ads (or lack of them) are factored out of the EMR pricing, the ad-removal-for-a-price model tends to work better for smaller practices.

Based on this, I feel like we’re going to see some steep discounting in EMR prices.

So, from the Department of Human Perversity, here’s my list of current EMR trends that don’t make a whole heck of a lot of sense. (I know, it’s easier to complain than to actually be out there fixing things, but hey, being a critic is what I do best!)  In no particular order, here you have ‘em:

*  EMRs Are Expensive, But Free Ones Are Bad:  OK, OK, before I have our friends at Practice Fusion on the horn telling me I’ve got it all wrong, yes, I realize that the free, Web-based EMR market has legs. But too many folks still seem convinced that TANSTAAFL (there ain’t no such thing as a free lunch).  OK, I admit that sometimes TANSTAAFL does apply, but in this case, with free and cheap EMR options available, where’s the hard-line resistance coming from?  For non-techies to be afraid of Linux — at least in its early days of commercialization — this, I get. But insisting on paying double for the privilege of getting an unwieldy system that’s a pain to upgrade?  Not so much.

* Let’s Keep Our Paper Records Forever:  So, as I’ve noted here before, some hospitals expect to store paper records for five years or more going forward, including some with mature EMR installationsin place. Keeping paper charts in play is certainly understandable from an emotional standpoint. Who wants to give up their way of life?  And who knows what will happen if your EMR balks, gets junked and loses vendor support, displeases one of your key physicians, gets hit by a bus or…whatever (fill in your nightmare scenario).  All sarcasm aside, this is obviously a very challenging transition. But if you’re going to go swimming, it helps to actually immerse yourself in the water. Besides, paper and electronic medical records largely aren’t compatible anyway, so what’s the point of maintaining both?

* If Our Templates Don’t Suit You, You Can Always Crawl Under A Rock:  I’ll admit, I started out a bit skeptical that specialty EMRs were a big deal. After all, I reasoned, just how different would the underlying data structure and workflow for a cardiology and a psychiatry practice be?  Actually, a lot, I’ve come to find out. In fact, I’ve come to realize that most EMRs aren’t flexible enough to suit two different medical practices within the same specialty.  Sure, vendors offer customizable templates, but far too often, using them is so painful that staffers and doctors largely give up. That’s not only non-good, it’s dangerous, if it leads to clinicians working ineffectively.  Now, I realize that enterprise software vendors in and outside of healthcare will force the customer to do the adapting if they can get away with it. But the big boys’ indifference seems particularly pointed in this case.

I have many other EMR industry pet peeves to share, but to my mind, these are  having the biggest effect on the process of EMR adoption.  So, do  you think I’ve hit the real pain points?  Do you have others to share?

The following is my personal list of pet peeves about the way vendors conduct themselves during the sales process. This comes from observation, not direct experience, as I’m a researcher rather than a techie — but I hear about these issues over and over.

Top Three Annoying Things EHR Vendors Do To Sell
(in no particular order):

1.   Can’t explain how their product actually solves physician problems:  Tech companies can’t help being a little, er, technical when they describe their products, and EHR firms are no exception. Too often, they end up writing their documentation to please their colleagues rather than their customers.  Others, meanwhile, entice customers with shallow nonsense (oh, and I mention spectacular, $200K boothes at HIMSS) then throw a confusing technical mess at buyers when they’re ready to look closer.

2.   Claim their product is a Swiss Army knife: Even the biggest, baddest enterprise EHR package will eventually need significant add-ons such as master data management technology.  Not only that, implementing any high-end EHR product will call for bridging technologies that integrate everything from labs to PACS.

3.  Slack off on support after the sale: Oh, this is a classic one for just about any software vendor, but it’s particularly damaging where EHRs are concerned.  Vendors often overpromise and under-deliver when it comes to tech support. The wise IT manager will evaluate what they need in the way of training and support, then make sure they get absolutely everything on the list.

I’ll be interested to see if you disagree with these, or come up with others. Just shoot me a note at katherine@emrandehr.com.

John’s Note: I got the following message from an EMR vendor a while back. I’ve removed the specific names of the EMR vendors to protect the innocent (and guilty in some cases). Plus, the names of the specific companies are tangential to the issue of ratings services like KLAS.

I’m sure this post will drive some interesting discussion in the comments.

I have been talking with [someone] at KLAS since HIMSS about WHY the KLAS data is either 1) Losing Relevance, or 2) Actually Misleading Providers.

[KLAS representative] told me in April that the average annual “accesses” to the KLAS data was about 17,000, while in 2010, they had over 14,000 through mid-April. Big trend change. ONC-driven, no doubt.

I had a discussion with [KLAS representative] at HIMSS and since, outlining how the KLAS data can and probably IS misleading clients. How? For instance….[EMR Vendor A] gets high marks…almost as high as [EMR Vendor B]
.
They have two “konfidence” checks on their data for the 6-25 provider practice size category (KLAS has 1-5, 6-25, and 25+, I believe as their categories, and vendors must submit their reference accounts in those partitions).

If you are a provider who sees high marks for [EMR Vendor A] in the 6-25 provider space…with all the good supporting comments…..well above the other vendors….you would probably rely on that data to decide they have to be on your short list. But everyone knows that [EMR Vendor A] serves mostly primary care and ob/gyn practices. They have adapted templates and have references for those accounts. What if you are an orthopedist or ophthalmologist…or other specialist. They have almost NO references for that. The KLAS data does not break it out. You may be badly mislead….and find out shortly after spending tens of thousands of dollars…that it wont work at all for you.

We have asked them to break out the data by specialty… they know who they are talking to. They know what each practice is. Not hard to add the question…so the data can be sliced that way. Tremendous value-add for ALL practices to know how the vendors break out. Guess what they are going to find out when they do that? And by the way…they ONLY gather data from accounts that have been installed and live for a certain period of time….no data on failed attempts or those that gave up using products.

KLAS agreed in principle it was a good idea to add specialty to their data. They even agreed to start doing it with the last reporting cycle, but didn’t have much time. All the data they have….not normalized by specialty.

LIKE THE GOVERNMENT, THEY ARE ASSUMING ALL SPECIALTIES CAN BE TREATED THE SAME AS FAR AS EMR ADOPTION GOES. Why do they think there is a 50-83% failure rate in the industry? Why has “meaningful use” not been defined for specialties before “certification” of a product can be decided? Does an orthopedist who does hip replacements, rotator cuff surgery and meniscus revisions…..report the same thing as doctors who treat diabetes, liver disease or other costly chronic-care conditions? Heck No.

I don’t think the market fully realizes how “homogenized” the KLAS data is….after all, if the average depth of the Mississippi River is only three feet…..why are there so many different size boats—-barges to sailboats—sailing in it each day?

Rob Tholemeier from Crosstree Capital Partners had an interesting article a while back on the Health Data Management blogs about ways that EMR vendors succeed. He provides 5 approaches that these EMR companies take to the EMR and EHR market. Here’s the 5 methods he identifies with a few of my thoughts after each:
Leveraging Size – I call these the Jabba the Hutt EHR vendors. They’re really big and powerful and no doubt will continue to sell a bunch of software since they have “leading vendor” name recognition. Rob correctly notes that they’ll continue to grow through mergers and acquisitions.

Specialization – I find this segment of the market really interesting. I’ve been seeing more and more of these specialty specific EHR vendors carving out their niche in the market. I still think the best play for a “leading EHR vendor” is likely to acquire a number of specialty specific EHR.

Regional Focus – Many people to want to “buy local.” There’s something really powerful about knowing your EHR vendor’s office is down the street and you can go and wring their neck personally if something goes wrong. < sarcasm >Not that anything would ever go wrong with an EMR. < end sarcasm font>

Suite Selling – I found this one interesting. Although, I think that it’s more of a factor for hospital EMR selection. I guess you could make the case that practices purchasing their EHR based on the hospital system purchase might fall into this category as well. Basically, the practice adopts a certain EHR because their hospital is subsidizing it or has a nicely built connection to that specific EHR company.

Advanced Technology – I’ve seen a few companies that have made this pitch. I still find this a challenge for an EMR company to make this pitch and be heard above all the EMR noise. However, I think if anyone is going to do it, I think it will likely come in the user interface.

An interesting way to stratify the various EMR companies. Are there any other categories of approaches that he missed?

In all my years writing about healthcare and technology, I’ve never seen such a storm of enthusiasm over a new medical device.  If the newspaper and blog coverage is any indication, we have no less than a moral duty to give an iPad to every practicing physician, stocked with a variety of the coolest medical apps.

In fact, Apple itself has jumped on the bandwagon, with its most recent iPad2 commercials displaying medical apps.

This, of course, has serious implications for EMR developers.  If the iPad is eclipsing even the desktop and smartphone as a primary means of accessing medical information, their focus will have to shift from a traditional client-server model — and perhaps even existing SaaS options — to one which is more modularized.  Their assumptions  about users’ interaction with their interface will need to be different as well.

The thing is, despite all of this discussion, I’ve seen no stats to back up the notion that even tech-friendly doctors see iPads as indispensable.

Where the iPhone (or at least smartphones generally) are concerned, sure, there seems to be plenty of research documenting that most physicians rely on them. But while there’s lots of anecdotes circulating about the iPad’s central future in medicine, none of the research firms covering the healthcare industry seem to have documented this trend.

What’s more, as a consumer whose family sees a lot of specialists — a few of us have chronic illnesses — I’ve never seen an iPad in anyone’s hands.  Walk into a coffee shop in the prosperous D.C. metro suburbs where I live, and sure, at least one consumer will have one.  But in DC medical offices, not so much.

Now, don’t get me wrong, if I were a product manager with an EMR vendor, I’d create an iPad interface and trumpet its existence to the world — it makes marketing sense if nothing else. One vendor which has already taken this tack is DrChrono, which prominently advertises the iPad version of its free EMR.

Regardless, I’m still waiting to see more evidence that the buzz around the medical iPad is more than just the expertly-crafted legends Apple creates around its products.  (Should we sense some Pixar magic here?) Anyway, just because everyone says something’s cool doesn’t mean it is.  I mean, we learned that in high school, didn’t we?

If I were running a medical practice — and knew I had to roll an EMR soon — I’d be banging my head against a wall.  While there’s plenty of talk about the reasons for EMR adoption (in some cases, 44,000 reasons) what consistent, reliable, accessible sources of information can physicians find on the subject?

You may think, “doubtless there’s plenty of colleagues to talk with, not to mention news stories and how-to sites out there, for physicians wanting an EMR,”  but it’s really not that simple:

*  Sure, physicians trust their peers, but with so few having gone whole-heartedly into the EMR game, there’s not a ton of peer support available — and that holds adoption down. You gotta love the whole chicken-and-egg dilemma here.

* Medical practice journals toss off the occasional article on the subject, but they’re often just highlighting a study on how many their peers are also looking into buying in (big help!)

*  Consultants of unknown bias pump out advice on how to choose an EMR, but it’s scattershot and often goes too technical or gets long-winded

*  Bibles of the medical news industry may pop out a case study or two on EMR adoption, but they’re usually focused on big players like the Cleveland Clinic, not the two- to five-physician practices that really need feedback.

* Sure, there’s the Regional Extension Centers, but I’m having trouble visualizing how an already intimidated doctor would bring him or herself to spend enough time with them to benefit.

* Of course, vendors are happy to tell nice stories about EMR use by small practices, but everyone takes those with a grain of salt, with good reason.

In other words, for a problem of such importance, there’s far too little appropriate guidance out there.

In truth, some medical societies probably are reaching out, not to mention hospitals, health plans and government, with reasonably useful suggestions.  But it’s still like a violent info thunderstorm out there.  Unless physicians find an ongoing source of reassuring guidance, which seems relatively unbiased and thorough, many are likely to hang back.

It comes down to this.  Incentives or no, no small business in or outside of medicine makes such a significant purchase without feeling comfortable — and if I was a low-tech doctor, I wouldn’t know how to get there. This can’t be good.

About 30 years ago, when cable television hit its stride,  pundits watching the industry assumed that home adoption would quickly climb to near 100 percent. Instead, for a variety of reasons, consumer adoption more or less froze at the 50 percent mark for many years.

Maybe the industry didn’t their pricing strategy right; maybe consumers were perfectly happy with broadcast television; or  maybe the existing broadcast networks greased a few palms and helped regulators slow down its growth in subtle ways.

In any event, the cable industry has improved its performance enormously; in fact, it hit 70% in the late 90s, though that number has fallen significantly as satellite providers have horned in.

So, why bring up cable TV in a forum aimed at dissecting the EMR business?  Because I think the cable industry’s experience is instructive in how we think about EMR adoption.

First, some data points.  According to study released in January by the CDC’s National Center for Health Statistics, 50.7 percent of physicians were using EMRs in their offices in 2010.  That’s a dramatic upswing from previous years, the agency noted.

Of course, practices are eager to collect Meaningful Use incentives if they can.  Also, as older physicians retire, younger, more-wired MDs are taking up the EMR banner. (In fact, CDC data concludes that the younger a physician is, the more likely they were to adopt EMR technology.)

Not only that, hospitals are helping to grease the skids, with one-third offering to subsidize EMR buys and 60 percent offering doctors access to the facility’s EMR, the CDC found.

All of that sounds great, particularly if you’re an EMR vendor.  But I think it’s a bit early, as it was for cable pundits, to predict that EMR adoption is at some kind of tipping point.  Whiz-bang technology always looks great from the peanut gallery — especially to analysts and editors — but it often looks different on the ground.

Not only do I think exponential growth is unlikely, I’d argue that adoption by physicians will be painfully slow for at least a few years more, gaining say, 5 to 7 percentage points a year at best.

Why do I feel that way?  Here’s a few reasons:

*  Few (if any) vendors can honestly say that introducing their product won’t bog down a practice and trash its productivity for months at least.  Doctors know this.

*  Smaller practices don’t, and aren’t likely to, have full-time IT staffers.  Even practices that want to adopt don’t have the reassurance of a dedicated IT brain that knows their needs. Under these circumstances, buying an EMR is a scary investment.

* Other trends that might spark EMR adoption — such as the emergence of RHIOs/HIEs — are moving at a snail’s pace.  If a doctor doesn’t have the added incentive of sharing patient data to spark adoption, that’s one more reason to delay.

Look, maybe I’m being pessimistic, or short-sighted. But I simply don’t think the EMR vendor market nor the physician buyer side have gelled enough to spark a revolution. I guess we’ll just have to wait and see.

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?