Most of the critiques I read of EMR design ding the EMR for its difficulty to use or its inability to accomodate the workflow of the institution that bought it — and of course, sometimes both. What I’ve never heard suggested, however, is the following idea proposed by Chuck Webster, a guy who clearly doesn’t stop short when he decides to study something. (He’s an MD, an MSIE and an MSIS in intelligent systems design, which is only one of the reasons I think he’s onto something here.)

In a thoughtful and nuanced blog entry, Dr. Webster outlines the work of a pioneer in usability design, Donald Norman, and comes away with the conclusion that the current trend toward “human-centered design” might actually be a mistake.  What a pain — health IT limps along catching  up with a trend from the 1980s, and now may be too late to catch the bus.

In any event, Dr. Webster argues instead of focusing on human/user-centered design, EMR vendors should be focused on activity- or process-centered design. I love what he says about one of the potential problems with human-centered UIs:

Optimization around a user, or user screen, risks the ultimate systems engineering sin: suboptimization. Individual EHR user screens are routinely optimized at the expense of total EHR system workflow usability…I’ve seen EHR screens, which, considered individually, are jewel-like in appearance and cognitive science-savvy in design philosophy, but which do not work together well.

It’s better, he suggests, to have EMRs model “interleaved and interacting sequences of task accomplishment” first and foremost. For example, he writes, key task collections that should be considered as a whole include workflow management systems, business process management, case management and process-aware information systems.

While there’s much more to say here, of course, I’ll close with Dr. Webster’s words, who once makes his point with wonderful clarity:

User-centered EHR design does help get to good EHRs. Good isn’t good enough. If EHRs and HIT are going to help transform healthcare they need to be better than world-class (compared to what?). They need to be stellar. Traditional user-centered design isn’t going to get us there.

The question I’m left with, readers, is whether you can have your cake and eat it too. Does one side of UI/UX design literally have to be jettisoned to support the other?

If I were part of CMS, I’d be pretty annoyed right now: Apparently, state Medicaid programs are beginning to be a wet blanket in the race to get providers up to Meaningful Use standards.  According to InformationWeek, a dozen states aren’t yet paying out Medicaid incentives, and some of those haven’t even launched incentive programs yet.  Not good news, to say the least.

According to a new post on CMS’s official blog, CMS has handed out Medicare and Medicaid incentives to more than 59,000 eligible professionals and 2,000 hospitals. It also noted that the Medicaid program alone had made more than $1.8 billion in MU incentive payments between January 2011 and the end of last month.

That’s not a bad start, but the slow pace of some Medicaid MU programs is a drag on meeting CMS’s overall goal, which is to have 100,000 providers get MU payments this year.

True, some states are clearly doing their level best: Ohio, which wants to reach 40 percent of eligible providers, Washington, whose goal is 7,000 EPs and hospitals, California, which is trying to get 10,000 providers set up for Medicaid incentives by June; and New York, which hopes to get 6,000 providers get incentive payments in 2012. And 43 states in total have launched a Medicaid incentive program and begun registering applicants, the article reports.

But then there’s the naughty states, which include Hawaii, Idaho, Minnesota, Nebraska, Nevada, New Hampshire, and Virginia — which haven’t launched their Medicaid incentive programs at all. As of December, however, CMS expects (demands?) that all states be making Medicaid incentive payments by June, according to a CMS official quoted in the story.

In the grand scheme of things, I’m pretty confident that Medicare, not Medicaid incentives, are going to drive the train here.  That being said, it is worth asking whether the states’ lagging efforts will create serious problems for the MU program. As I see it, it could go either way, but regardless, it’s not a good sign.

During my recent visit to my daughter’s pediatrician, I was pleasantly surprised to see a computer up and humming along in a corner of the exam room. The last time we had been in, some six months before, that same piece of equipment sat shrink-wrapped (as it had been for a few months even before that), waiting for an eager clinician to tear open its plastic casing and put its digital capabilities to good use.

I had been dreading this particular appointment – our first with the one pediatrician left at the practice. Our usual doctor had left a few month earlier for parts unknown, so I wasn’t sure who – or what – to expect. The advice nurse who made my last minute “work-in” appointment was kind enough to make sure I understood that due to the second doctor’s departure, we would likely wait an extremely long time.

Our wait, which ended up being no longer than usual, gave me time to do a bit of snooping around the new computer. No keys or mouse were touched, but I did notice that NextGen was the practice’s EMR of choice. Yes, the nurse did have her back turned to us as she asked me questions about the reason for our visit and entered responses into the EMR. When I asked her if she liked the new system, she gave a rather noncommittal response in close approximation to “some days I do, some days I don’t.”

I’m guessing she may have bigger issues to deal with, such as assisting the patients of a double-, sometimes triple-booked pediatrician. The single-doc situation made me wonder how much training the practice’s staff had time for before and during go-live. I could certainly believe that follow-up training will take a backseat until a second pediatrician is brought into the fold and everyone gets back to a somewhat normal workload.

So how do small practices in similar situations do it? How do they find time for EMR training when overscheduled? Do vendors often step in and help with extra resources? How long do practices go before hiring additional staff? (That’s an off-topic question, I know, but one I’d still like an answer to.) I’d like to think that in the long run, the new EMR would of course help make everyone more efficient, and us patient parents more satisfied. Let me know what you find out in the comments below.

Back in 2010, Epocrates had its EMR ducks in a row. The company, known best for a very popular smartphone-based drug interaction database for physicians, announced plans to release a mobile SaaS EMR.  While Epocrates was jumping into a market more crowded than a barrel full of monkeys, one could see where leaders might see an EMR as an extension of the relationship it already had with physicians.

Now, Epocrates leaders have said “oops” and announced that they were killing the product,  telling investors and the public that building the darned thing was distracting it from its core business.  It does seem that the company was struggling with the EMR rollout process:  it didn’t roll out its first-phase product until August 2011 and didn’t get its Meaningful Use certification until February of this year. But this is the first time I’ve seen a company kill a product at this stage of development, particularly in such a high-profile manner.

It must have been more than a bit embarrassing to make the announcement during HIMSS12 when, of course, companies traditionally kick off products they’re planning to sell vigorously. As Epocrates was making plans to dump or sell their EMR, the company’s CMIO, Tom Giannulli, MD, was pitching the company’s new iPad EMR to editors.

As Epocrates itself pointed out, there aren’t too many dedicated iPad EMR offerings out there. So in theory, this should not have been a waste of the company’s time.  On the other hand, with the iPad still a new frontier for EMRs, we still don’t know whether it will ultimately work as a platform of choice for physicians.  As we’ve previously discussed on this blog, the iPad seems to be a pretty good medium for reading data but a very awkward one for entering data. Whether that’s a fatal flaw remains to be seen.

Truthfully, this looks like a failure of execution from start to finish, rather than a product that couldn’t possibly work. But these are tough times. Even the best execution may not work; and if so, Epocrates was probably wise to fold its cards before further damage was done.

For quite some time, talking heads have noted that EMRs will be an essential part of ACOs, so much so that most doubt you can have a successful ACO organization without one.  What I don’t see asked as often, however, is whether EMRs are shaping the future of the ACO movement, both negatively and positively.

What would an ACO look like, if it could exist at all, without an electronic record or HIE in place?

* There would even more mistakes and delays in sharing patient records, as one can hardly expect a larger group of institutions to make *less* mistakes

*  ACOs could launch without having to spend millions of dollars on EMR software, hardware, training and support

*  Clinical workflow would remain the same, generally, even if doctors were forced to include larger numbers of co-workers in their network

And how are ACOs working with EMRs in place?

*  Aside from limited case studies in individual institutions , it’s not clear whether EMRs are turning large, newly assembled care organizations into safer places to get care.

*  ACOs are forming more slowly than they might be, arguably, because a comprehensive EMR is part of t he cost of doing business

* New clinical workflow patterns are being forced upon clinicians, cutting across multiple institutions. While this might ultimately increase efficiency, it’s hard to ignore how many human hours are being invested (or wasted, depending on your position) on new technology.

As you can see, I come down on the “EMRs may not be all they’re cracked up to be for ACOs” side of things. Now, I’d concede that I haven’t been completely fair — I know EMRs have yielded great benefits for some groups of institutions– but I’d say the jury’s still out overall.

In my conversations at HIMSS a few weeks ago with providers and vendors, I heard more than a few references to user-friendly EMR design, easy-to-use dashboards and the bar that has been set so high by Apple and the iPad. I had a chance to chat with David Carleton, VP and CIO at Heritage Valley Health System in Pennsylvania, about the adoption of the iPad in the clinical setting, particularly with regard to EMRs. Carleton, with the assistance of dbMotion, helped a team of docs and IT staff at HVHS in Pennsylvania develop their own EMR iPad app.

In a nutshell, the internet Clinical Access Portal (iCAP) app organizes and harmonizes data captured and stored in various systems – including its Allscripts Enterprise ambulatory solution and its soon-to-be-completed Allscripts Sunrise Clinical Manager, as well as the ClinicalConnect HIE in western Pennsylvania – and delivers Continuity of Care Documents (CCDs) to HVHS providers via the tablet. Named to the 2012 Top 100 Integrated Healthcare Networks, HVHS seems to be placing a high priority on enabling its facilities to be truly interoperable with one another. It made sense to me that the hospital would want to better enable its physicians with a handy iPad app, but I wondered why they took the in-house development route.

Carleton explained to me that one of the reasons was physician buy-in. (You can view more of our chat in the video below.) Apparently, the key to getting physicians to adopt and consistently use the tablet and app was to have them on board from the very beginning. Involvement in the design process let them have a say as to what would best fit their workflows.

With the release of the iPad 3, the details of which were announced yesterday, I’m willing to bet we’ll see an up tick in clinical interest in the iPad and a corresponding surge in app development – in-house or otherwise.

Are you aware of other facilities getting into the EMR app game? Please share the details in the comments below.

Today I got a call from an executive recruiter who wanted to know, in essence, where the EMR market was going.  Aside from the usual chatter about Meaningful Use, talent shortages and HITECH, one question she asked made me think: “What do you think is the main thing someone like me should know about the health IT market.”

Having pondered this for a while, I realized that the answer is fairly simple. Above all, anyone who wants to understand health IT needs to know two things: a) That health IT leaders need to be change leaders, more than ever before in the industry and, more importantly, b) that the EMR is at version 0.5 when it comes to maturity and integration into the life of most hospitals.

Yes, I mean version 0.5. We’re talking barely in beta, when it comes to solid integration, staff training, enough institutional knowledge so people can share and learn and a high-performing system that doctors love.  Sure, a few hospitals (1 percent, as I recall) have reached that legendary HIMSS Analytics stage 7, but most are lucky to have gotten their Meaningful Use Stage 1 payment into the door.

When you consider that a large number of CIOs doubt they have the man/women power to complete their Stage 1 implementation, the picture looks even grimmer.  Not only are the EMRs immature, they’re largely being implemented and run by consultants who will cut and run with their experience bank, as they have little ability to share it other than in (to staff and doctors at least) boring reports.

Bottom line, I’d argue that it will be a whopping five to seven years, at least, before EMRs meet either HIMSS Analytics criteria for maturity or my personal Zieger seat-of-the-pants model.  I hate to say that it could even be 10 years, but I see it as a possibility.

The reality is, government can be powerful, and big financial incentives are tasty, but you can’t force an industry to change overnight just because it would be really, really cool.

If you don’t check out the HIMSS group on LinkedIn from time to time, you should. I always pick up something to think about when I visit, and this time was no exception.

A group of IT pros, most of whom seemed to have plenty of institutional memory of EMRs gone by, were talking about whether the current leaders of the EMR vendor pack would take over and most of the rest fall away.  The consensus, not surprisingly, was that hospital CEOs are herd animals, and that a few leaders are likely to take most of the market.

As things stand today, even EMRs that seem to be a better fit usually lose to the Epics, Cerners and Meditechs of the world, writes Richard Rauber, FHIMSS.

“Let’s say the preferred EMR has 10 clients similar to their facility, and the second choice has 75 clients in the same bed range with a high level of user satisfaction. Is the risk/reward ratio low enough to go with the smaller vendor? It today’s market it would be unlikely.”

If these posters are right, the hospital market is going to standardize on a dozen or so of the most successful vendors. Unfortunately, that’s likely to lead to some really nasty implementations, suggests Terry Montgomery, PMP: “I had such a project last year. They had to move the go live date three times and there were still bugs they had to fix.”

That being said, I think there will be a lot more dancing when it comes to the physician EMR market.  You’ve got breakout models like the no-cost Practice Fusion — and its bundle of VC cash to fuel the fire — iPad-based DrChrono, Free Mitochon PMS-EHR-HIE and a growing number of elegant, doctor-crafted implementations like SOAPware and Amazing Charts.

While the dynamic of hospital IT purchasing is to standardize on the big boys (the old “nobody gets fired for buying IBM” syndrome), physicians can’t afford to buy a system just because the practice across town thought it was cool. Not that such doesn’t happen, but it’s less likely.

I predict that doctors will have some great options to choose from when they hit HIMSS13 next year, systems integrated intelligently with revenue cycle needs but also cleanly designed and physician friendly.

The smaller EMR companies focused on doctors are just doing a better job of mirroring a doctor’s process, there no doubt in my mind. If only such logic would float upward to the billion-dollar boys behind the hospital giants.

Full Disclosure: Practice Fusion, Mitochon, SOAPware and Amazing Charts are advertisers on this blog.

Over at the august halls of the National Institute of Standards and Technology, researchers have been compiling data on what makes EMRs usable. A year ago, in April 2011, NIST presented a draft set of usability standards. At the same hearing, a wide range of academics and scholars got up to talk about what they saw as they key issues — including whether EMR workflow should be changed to make it cost-efficient.

Since then, from what I can tell, there’s been a lot of noise but little light shed on the design specs a truly usable EMR should adhere to.  There’s been some progress in the development of HIE connections between EMRs, some worthwhile work EMR return on investment and even some improvements that might leverage EMRs to help doctors collect more from patients.

Talk to many doctors, and they’ll tell you their EMR stinks. Why? Largely because workflow is still inefficient and the “click burden,” which can drive doctors through a dozen steps to get tasks handled, hasn’t been reduced any too much. Some older docs I’ve spoken with even pine for the rough-hewn EMRs of 20 to 30 years ago more, which were at least built by their colleagues.

Honestly, I don’t expect the “awkward interface” problem to go away anytime soon. But while we stew on this issue, you might be interested to learn that NIST is taking over a few related problems in which it could conceivably make a real difference.

A few months ago, NIST released the 16th and final draft of its recommendations on definition of cloud computing. (Talk about insisting on getting it right!)  Not everyone in the health IT industry is even aware that NIST has kicked out a cloud standards document, which our friend Shahid Shah, “The Healthcare Guy,” is urging people to get onto their radar.  Maybe this time, NIST has a chance to actually standardize before an industry runs while with its own implementations of key technology.

I think I’ll finish with Shahid’s comments on the subject, as I think he’s pretty clearly got it right:

My strong recommendation to all senior healthcare executives is that we not come up with our own definitions for cloud components – instead, when communicating anything about the cloud we should instruct our customers about NIST’s definition and then tie our product offerings to those definitions. The essential characteristics, deployment models, and service models have already been established and we should use them. When we do that, customers know that we’re not trying to confuse them and that they have an independent way of verifying our cloud offerings as real or vapor.

If someone asked you how long it’s been since someone lit up an EMR, what would your guess be?  Five years?  Ten? Even 20? What if I suggested that the first EMR was installed 50 years ago in an Akron hospital?

According to IBM, the first EMR was rolled out at Akron’s Childrens Hospital in February 1962.  In Big Blue’s own words:

Though Dr. Lawrence L. Weed is credited for developing the first electronic medical record, the so-called Problem-Oriented Medical Information System (Promis), starting in 1969. But IBM, working with Akron’s Children’s Hospital, implemented a system years earlier that would be the grand-daddy of today’s EMR.

Other early players in EMR evolution included doctors at the University of Vermont, whose PROMIS system and later the POMR (problem-oriented medical record) followed in the late 1960s, as well as the Mayo Clinic. Still, it seems we may have IBM and a pioneering children’s hospital to thank for much of what we discuss so passionately here today.

By the way, it’s interesting to note that while the technology has evolved in astounding ways, the EMR as a concept hasn’t changed nearly as much.  For example, even back then execs were noting that nurses were spending far more time handling paper than they needed to (and that one patient could generate 50 forms, a number which I’d bet still hasn’t changed). It’s amazing that a problem we defined 50 years ago still defies easy solutions, but there you have it.

Meanwhile, courtesy of Scribd, check out the actual IBM press release  on the subject (typed on an oldie-but-goodie typewriter):