Not long ago, I recently posted an item on HospitalEMRandEHR.com discussing how one hospital dropped plans to distribute iPads as front-ends for its Cerner EMR.  Doctors at hospital, Seattle Children’s, gave the iPad very bad reviews as an EMR-connected device, in part because they felt that Cerner’s system was too hard to use via a Safari browser.

Since then, a few readers have commented on the story, and interestingly, they’ve offered more nuanced feedback on what works (and doesn’t) in deploying a tablet as an EMR device for clinical use, including the following:

* Deploying the iPad initially offers a patient “wow factor” — in other words, it may make providers look hip and up-to-date technically — but that doesn’t last very long.

* Even a well-designed, tablet-native tablet app may still be frustrating for clinicians to use, given the high volume of information they need to enter. (Paging through a dozen screens is no fun.)

* When choosing a tablet, be aware that the physical performance of the tablet (especially the touch screen) can be a big issue.  If clinicians “touch” and the screen doesn’t respond, it can throw them off their stride.

It’s hard to argue that hospitals (and medical practices) should take mobile access to EMRs seriously. And anyone here would know, most organizations are.  After all, now that health IT industry is looking hard at mHealth, smart new ways to use mobile devices in care seem to be springing up daily.

But before you dig too deeply into your mobile strategy, you may want to hear more clinicians on how their mobile EMR usage is playing out. Call me a curmudgeon, but it seems to me that it may still be too early to invest big bucks in a tablet for mobilizing your EMR just yet.

Don’t get me wrong: I’m convinced that someday, every doctor will enter and access patient data via some sort of mobile device. But it seems that there’s some fairly important technical issues that still need to work themselves out before we can say “this is how we should do it.”

Note:  The following is not to be taken at face value, exactly — I’m not literally convinced that it’s time for a revolution — but you might see a point or two here that are worth considering further.

Doctors, are you sick of having an EMR pushed down your throat by administrators and IT leaders that don’t care how disruptive or painful the change may be?  Do you feel like your complaints and concerns aren’t being heard?  Are you actually afraid a patient will be hurt someday because of the EMR’s limitations?

Well, I say it’s high time you get radical and OccupyYourEMR!  Get in there and resist until your (absolutely critical) voice is being heard.

If you don’t, you know you’re going to be steamrolled into using a platform that’s awkward, ugly, inflexible and slow — in short, a system only the IT admin and hospital board who funded it could love.   Maybe you’re not ready to stop working, but what if you refused to log in?

As things stand, you have little to gain and a lot to lose by blindly kowtowing to EMR adoption demands.

Hey, if Hospital X installs an EHR and it seems to work, the CIO and the CEO and the board of directors look like geniuses. Some of them will probably get big bonuses if everything falls into place just right.

You, on the other hand, will be lucky if the new system doesn’t cut your work pace in half, confuse you and make charting a painful chore. Oh, and if things really go badly, you’ll harm or kill a patient because you didn’t read the EMR right.  Of course, the hospital will be right there beside you offering the best legal defense money can buy, right? (Uh, not really…)

Yes, there are some stories out there about EMRs that actually improve patient care and make doctors’ lives easier, but let’s face it, there’s a reason we don’t publish a ton of those here (or on sister blog Hospital EMR and EHR).  I’m not suggesting that all EMR rollouts are a mess, but few are a walk in the garden either. And it’s more common than you might think for a provider organization to go through a second or even a third installation before everything works.

Hey, don’t misunderstand me, I still believe EMRs are going to be a positive force over the long term.  In the mean time, though, some clinicians will be casualties — either becoming burned out by new work expectations, hating the new process or even making dangerous mistakes. Don’t be one of them.

Demand an EHR that helps your workflow, helps you provide better patient care, makes your life better, and lives up to the expectations the EMR salesperson made. An EHR that does those things will be welcomed by almost all doctors and other staff.

For those of you that work in the Hospital EMR and EHR market or have an interest in hospital healthcare IT, you should go over right now and make sure you’re subscribed to our sister site: Hospital EMR and EHR. The content that’s being created on that site is phenomenal.

For example, Chris O’Neal from KATALUS Advisors just finished a series of posts covering the Critical Access Hospital EMR & EHR market. Here are the posts from the series:
How Big is the Health IT Market for Critical Access Hospitals?
Pressures on Critical Access Hospitals – IT Budgets, Competition and IT Talent Retention
What Are the Health IT Trends Working in Favor of Small Hospitals?
Which Health IT and EHR Vendors Should Critical Access Hospitals Consider?

I’ve got another post titled The Argument for Meditech on the way as well. I’ve really enjoyed working with Chris and KATALUS Advisors on these posts and I believe we’ll have even more great Hospital EMR and EHR content from them in the future.

Plus, many of you probably remember many of the great posts here on EMR and EHR by Katherine Rourke. She has such a love for hospitals, that Katherine’s now posting on Hospital EMR & EHR. You can find all of her posts here.

In my ongoing series of Major EHR Developments from John Halamka (see my previous EHR In The Cloud post), his second major EHR development from the Technology Review article is: Modular Software Unleashes Innovation. The following excerpt from his article sums it up well:

Until very recently, innovation in medical IT has depended upon the development schedules of a few very large vendors who sell hospital systems with $100 million price tags. In the future, electronic health records will become increasingly modular, similar to the online app stores where consumers download games or programs for their phones.

The idea of modular healthcare IT has been around for a long time. I think I first saw this concept when I learned about a group called the Clinical Groupware Collaborative. I haven’t heard much out of them recently, but every once in a while I see that they’re still working to make Halamka’s comments about modular EHR software a reality.

I’m certain that Judy from Epic would argue that such modular EHR software is a risk to the healthcare industry. She’s probably right. There are risks to modular software. However, there are even more risks and disadvantages associated with a monolithic EHR vendor that won’t interact with other modular clinical software. I believe that one day this will come back to bite Epic as new CIO’s who weren’t part of the $100 million hospital software purchase will start to embrace a more modular strategy.

Turns out that I think providers will actually be the strongest proponents of the modular strategy. They’re already buying mobile devices with money out of their own pockets and so they’re going to start using apps that will help them provide better care. Hospitals will have a hard time controlling it and they’ll eventually realize that the best way to control it is to embrace it.

The most unfortunate part of this EHR development is that it’s going to take a long time for this development to become a reality. However, little by little we’ll get there.

As most of you know, John Halamka is publishing content everywhere. In fact, maybe I should see if he’ll publish some here. Halamka is really smart and respected by many for good reason. So, I was intrigued to find an article in the Technology Review (an MIT publication) where Halamka higlights what he considers the major EHR and healthcare IT developments over the next five years.

I’ve been doing a number of series lately on EMR and EHR & EMR and HIPAA and since people seem to really like them, I decided I’d make Halamka’s major EHR developments into a series as well.

The first Major EHR Development is: EHR In the Cloud

In the article above, Halamka offers some interesting comments about doctors being doctors and not tech people, the issues of privacy in the cloud and hospitals leaning towards “private clouds.” Let’s take a look at each of these.

Doctors Don’t Want to be Tech People
While there are certainly exceptions to the rule, it’s true that most doctors just want their tech to work. They don’t want to spend a weekend installing a server. There’s little argument that a SaaS EHR requires less in office tech. This fact will end up being a major driving force behind the adoption of SaaS EHR software over the client server counterparts.

Certainly, many doctors will still feel comfortable with their local IT help doing the work for a client server install. Also, many still feel more comfortable having their EHR data stored on a server in their office. This issue will continue to fester for a long time to come. At least until the SaaS EHR vendors provide doctors a copy of their data which they can store in their office. Plus, SaaS EHR are much faster today than they were, but there’s still a few things that a client server can do that is just flat out faster than client server.

I still see the ease of implementation and “less tech” helping SaaS EHR software to continue to gain market share.

Privacy in the Cloud
The biggest problem here is likely that doctors aren’t technical enough to really understand the risks of data in the cloud or not. Plus, I think you can reasonably make an argument that both sides have privacy risks. Most people are becoming much more comfortable with data stored in the cloud. I expect this trend to continue.

Private Clouds for Hospitals
Halamka claims that he, “estimates that moving infrastructure and applications to my hospital’s private cloud has reduced the cost of implementing electronic health records by half.” Of course, we have a lot of possible definitions of “cloud” and I’m not exactly sure how Halamka defines his private cloud. However, anyone who’s managed client installs of EHR software, including client upgrades, etc knows some of the pains associated with it. I’d be interested to know what other savings Halamka and Beth Israel Deaconess Medical Center get from their “private cloud.”

Cloud and EHR
There’s one thing I can’t ever get out of me head when I think about EHR and the cloud. Someone once told me (sorry I can’t remember who), “The cloud has always won in every industry. It will win in EHR too.” I hate when people use terms like always and every, but I haven’t (yet?) found an example to prove that person wrong.

Time for the next entry covering Shawn Riley’s list of 101 Tips to Make your EMR and EHR More Useful. I hope you’re enjoying the series.

If you want to see my analysis of the other 101 EMR and EHR tips, I’ll be updating this page with my 101 EMR and EHR tips analysis. So, click on that link to see the other EMR tips.

60. Reporting, reporting, reporting, reports
What’s the point in collecting the data if you can’t report on it? I’ve before about the types of EMR reports that you can get out of the EMR system. The reports a hospital require will be much more robust than an ambulatory practice. In fact, outside of the basic reports (A/R, Appointments, etc), most ambulatory practices that I know don’t run very many reports. I’d say it’s haphazard report running at best.

Although, I won’t be surprised if the need to report data from your EHR increases over the next couple years. Between the meaningful use reporting requirements and the movement towards ACO’s, you can be sure that being able to have a robust reporting system built into your EHR will become a necessity.

59. Are the meaningful use (MU) guidelines covered by your product?
Assuming you want to show meaningful use, make sure your EHR vendor is certified by an ONC-ATCB. Next, talk to some of their existing users that have attested to meaningful use stage 1. Third, ask them about their approach for handling meaningful use stage 2 and 3. Fourth, evaluate how they’ve implemented some of the meaningful use requirements so you get an idea of how much extra work you’ll have to do beyond your regular documenting to meet meaningful use.

58. It they aren’t CCHIT certified take a really really hard look
Well, it looks like this tip was written pre-ONC-ATCB certifying bodies. Of course, readers of this site and its sister site, EMR and HIPAA, will be aware that CCHIT Has Become Irrelevant. Now it’s worth taking a hard look if the EHR isn’t an ONC-ATCB certified EHR. There are a few cases where it might be ok, but they better have a great reason not to be certified. Not because the EHR certification provides you any more value other than the EHR vendor will likely need that EHR certification to stay relevant in the current EHR market.

57. What billing systems do you interface with?
These days it seems in vogue to have an integrated EMR and PMS (billing system). Either way, it’s really important to evaluate how your EMR is going to integrate with your billing. Plus, there can be tremendous benefits to the tight integration if done right.

56. How much do changes and customizations cost?
In many cases, you can see and plan for the customization that you’ll need as part of the EHR implementation. However, there are also going to be plenty of unexpected customizations that you don’t know about until you’re actually using your EHR (Check out this recent post on Unexpected EHR Expenses). Be sure to have the pricing for such customizations specified in the contract. Plus, as much as possible try to understand how open they are to doing customizations for their customers.

Check out my analysis of all 101 EMR and EHR tips.

I’ve been looking over the next couple months and I realize I have more travel than I usually do. However, there are a number of events I want to attend and so I guess you got to do what you got to do. The good thing is that I love going to healthcare IT and EMR related events. I learn so much and meet a lot of really interesting people.

Here’s what I have on the agenda so far. I’d love to meet readers of the site at these events as well. So, let me know if you’ll be at the event or if you want to catch me before or after the event. (P.S. I posted something similar to this on EMR and HIPAA a while back, but the readership doesn’t crossover that much so I’m posting it here now).

Health Tech Next Generation – San Francisco August 12th – I’m actually doing an EMR panel at this event. Plus, I’m really excited with the meetings I have setup around this event. In fact, my trip to San Francisco is already packed. I’m also excited to see Guy Kawasaki speak in person.

Hospital and Healthcare IT Conference – Phoenix, AZ September 28-30, 2011 – I saw this conference and loved the Reverse Expo concept. Plus, I had an added interest in a conference like this since I am looking to dive deeper into the Hospital EHR world with my new site Hospital EMR and EHR. Katherine’s been writing over there for a bit now and she’s creating some interesting hospital EMR related content.

AHIMA Convention and Exhibit – Salt Lake City October 1-6 – I kept hearing people saying I should go to AHIMA. Well, it’s just up the road from me by where my folks live, and so I figured now was as good a time as ever to check out AHIMA. I don’t know what to expect really, but I’m sure I’ll learn a lot and get some new perspectives.

MGMA Annual Conference – Las Vegas October 23-26 – I can’t wait for MGMA to hit Las Vegas (my hometown). It will be my first time attending, but I’m excited to see all the EMR talk that’s sure to occur. Plus, I bet their exhibitor list will be right up my alley. I’ll be surprised if I make it to many sessions at all. I’ve been thinking of throwing a New Media Meetup at MGMA like I’ve done at HIMSS. What do you think?

There you have it. Any other conferences that I should try and squeeze into my plans? That’s pretty fully, but I could always be convinced for the right opportunity. I’m even talking to some people who organize a healthcare IT conference in Asia. I think a little international EMR and healthcare IT flare would be interesting.

I hope I get to meet a lot of readers at these various events. For those that can’t attend, I’ll do my best to bring you the best insights I can from each event.

Folks, if you’ve worked or presently live in the enterprise software world, you know that proving that you system generates a worthwhile return on investment is tricky.  Sure, vendors sales staffs usually offer some neat calculators that prove you’ll see 1000% return by next Tuesday, but internally, even they admit that making such estimates is more black magic than science.

While some of you may have different experiences, it seems to me that proving that an EMR can generate a return on investment reasonably soon is particularly difficult. Sure, most hospitals and medical practices know their annual revenue run rate, and have a good breakdown of their expenses in hand, but are they set up to detect the effects going electronic can have?

After all, while some enterprise software directly helps companies generate revenue — most obviously, lead-generation monsters like Salesforce.com — others earn their keep but preventing problems from happening or improving quality. And if a provider organization doesn’t know what their mistakes are costing them, and doesn’t pay a direct price when patients fare poorly, how can they pin down how much financial benefit their EMR produces?

Admittedly, as the quality data reporting bandwagon continues to roll faster, everyone from small practices to giant hospital systems are likely to have a better idea of where they’re slipping — they can’t afford not to, as they’re likely to forfeit incentives paid by Medicare or private insurers.  And most cases, it will take an EMR to organize, analyze and report out that data effectively.

Unfortunately, providers can’t expect huge bonuses just for buying an EMR. (OK, let’s be honest and admit that HITECH dollars are nice to have but not enough to make  or break a viable business.) So they’re having to make a leap of faith and invest in a system, sometimes a very expensive one, on the still-unproven assumption that it will offer tangible financial and organizational benefits in the near future. That’s gotta hurt.

Aggressive providers have been taking this risk for years now, and many have been very glad they did.  Not only have there been some nice examples of how hospitals and health systems have benefitted by their EMR investment, I’ve met doctors in small practices who absolutely rave about how productive their shift to EMRs has been. So there’s at least anecdotal evidence to support EMR buy-in.

Still, it sure would be nice if there was a one-size-fits-all ROI we could offer providers, or even a decent series of estimates. Right now, many are just going to have to fly blind.

HIMSS Analytics recently sent out some interesting results from a survey the did of hospital’s preparation for meaningful use. Here’s the results:

*Nearly one quarter (22 percent) of participating hospitals have the capability to achieve 10 or more of the required core measures in the meaningful use Stage 1 requirements.

*Some 34 percent of respondents have the capability to achieve between five and nine of the core measures for meaningful use.

*Just over 40 percent (40.47 percent) of the market indicated they have the capability to meet five or more of the menu items for meaningful use.

As lone data points it’s hard to judge if hospitals are making progress or not. I’ve heard many people say that hospitals are going full bore towards meaningful use and that ambulatory practices are slower to adopt EMR and meaningful use. I’m not sure this is totally true. Plus, the lead time needed to implement in an ambulatory setting is so much shorter than in a hospital. Even a hospital that owns ambulatory practices.

I’m told that HIMSS Analytics will be doing this same survey every couple months. I’ll see about publishing the results as I get them so we can compare the change.

Recent stimulus-induced EHR deals show sooner-than-expected adoption, especially in the hospital sector, according to investment firm Piper Jaffrey.

The second half of 2010 and all of 2011 are likely to show a large number of EHR deals, Piper Jaffrey analyst Sean Wieland wrote in his analysis Friday.

Wieland noted a growing trend of hospitals buying or subsidizing EHRs for physician practices.

“We continue to believe that mega-deals will continue as hospitals seek to capture first-mover advantage and HHS’ finalization of stimulus criteria will act as a catalyst for stand-alone physician/group practices to jump into the deal foray,” he said. -source

I’d be interested to know where Piper Jaffrey got their numbers that support their conclusion that EHR adoption showed better adoption in late 2010. I guess maybe they’re comparing their numbers to what they thought it would be. Maybe they expected adoption to be close to 0 and it was just over that.

I do think that Piper Jaffrey is dead on when they say that EHR deals will see a huge increase in 2010. It’s going to be the season for EHR adoption.

Do you think that the “mega-deals” involving hospitals subsidizing the EHR will be the reason?