On my far-too-frequent visits to my younger daughter’s pediatrician, I’ve noticed pristine new monitors and keyboards wrapped up and sitting in the corner of the exam rooms. Over the last six months, there they’ve sat, waiting patiently to be unwrapped and plugged in. “What’s the hold up,” I think? As a parent, I’m hoping this new system will offer the doctors e-prescribing capabilities. As a healthcare IT observer, I’m wondering why what I presume to be an electronic health record (EHR) is taking so long to come out of the box and into operation. Is it a question of resources? Is the facility waiting for a training team to be made available? Is there back-end infrastructure that has yet to be put in place? These are the things I think about while dealing with low-grade fevers and scheduled immunizations.

Needless to say, my interest is always piqued when I come across stories of pediatricians adopting EHRs and/or realizing the benefits of that technology. So when I came across news that Sandhills Pediatrics had received $184,000 in EHR incentives, I was intrigued. The Columbia, S.C.-based practice has been using an EHR from SRS since 2010.

“Even our initially most skeptical physicians became committed SRS EHR users in a very short period of time,” said Kevin O. Wessinger, M.D., president of Sandhills Pediatrics, in the release announcing the pay out. “All fourteen physicians and their staff value the efficiencies that SRS has delivered and the patient care and practice improvements that SRS has facilitated.”

I recently spoke with SRS CEO Evan Steele to learn more about how Sandhills implemented the EMR back in 2010, and the benefits they’ve realized from it.

This being the practice’s first EHR, what prompted them to make the move from paper to digital?
ES: “The driving force was the quality of care Sandhills was providing. With 4 locations and Saturday and Sunday office hours only at the central location, patient chart review was a big challenge. The patient charts that were housed at the satellite offices, because that’s where the patients were normally seen, and so were not available to review for weekend care. Additionally, the practice provides nurse triage in the evenings until 10:00pm and again, the satellite patients’ charts were not available.”

Did you, as the vendor, encounter any barriers to adoption from the Sandhills staff?
“No, we did not encounter any barriers to adoption. Our implementation plan is highly developed and assures 100% adoption. In addition, the Sandhills team’s dedication to success allowed them to achieve their EHR goals. Furthermore, the decision to implement the SRS EHR was driven from the top down. Sometimes the age of the physicians may impact adoptability. At Sandhills, 12 of the 14 physicians are under the age of 50 so they are more computer-savvy and willing to make the change.”

What sort of “extras” do the pediatric practices look for when selecting an EMR?
“Unique to pediatrics are immunizations. The SRS development staff worked closely with Sandhills on immunizations and pediatric growth charts. SRS secured the integration between Sandhills and the World Health Organization, developed a table for displaying and storing vaccine information, and enabled Sandhills to provide this information to their patients in a usable format.

“With a patient population of 57,000, Sandhills had to provide every kindergarten, grade school, and day care with proof of immunization. In the past, the practice had to hand-write 20,000 immunization certificates each year. SRS was readily available to provide a solution to this issue and saved the Sandhills staff many hours of aggravation. SRS created a form that auto-populates the immunization information so now the Sandhills staff no longer needs to hand-write each certificate.

The same process and benefits were developed for growth charts. The SRS EHR provides the patient’s age, and the Sandhills staff only has to enter height and weight, and this information auto-populates on the growth charts.

SRS created efficiencies, which coupled with our uniqueness in allowing physicians to continue to document notes as they are accustomed, has led to a successful implementation and positive EHR experience.”

How have clinical outcomes and patient satisfaction been improved since the EMR was installed?
“Clinical outcomes have improved as the physicians have access to pertinent clinical data at any time from any place. Additionally, the staff is quicker to respond to patient inquiries. They’ve experienced tremendous improvements in efficiencies and patient outcomes as a direct result of using SRS Order Management. Sandhills used to have manual paper tracking of lab tests and now with the SRS EHR, an expected date pops up in the system and if a test is not back by then, an alert is shown calling attention to the fact that it needs to be addressed.

“The patients, especially those seen on the weekends and evenings, have commented that they appreciate the improved and quick service. When they call in to the office with questions and concerns, they are comforted and given peace of mind knowing that the Sandhills’ staff is completely familiar and up-to-date with their situation.”

What do you think will be the next evolution of EHRs for pediatrics?
SRS Development recently unveiled vaccine inventory control. This process is entirely manual now, but the new enhancements will automatically track down the vaccine to the lot number. It’s also a double-check for safety that the lot numbers they have match what’s in computer. This is a double benefit – quality control and inventory control. This new development will especially find favor with the nurses, who are so happy that a daily occurrence that used to take 2 hours will now take 2 minutes.”

Here’s worthwhile some observations on how to drive improvements in EHR usability from Evan Steele, CEO of EMR, practice management and PACS systems vendor SRSSoft.  (Just for clarity, SRSSoft serves medical practices.)

While Mr. Steele’s comments may not be wildly original, I always like to see discussions of tricky issues like usability boiled down to a few key points, and he’s done a good job here. His arguments, with my commentary:

* Feedback from physicians and other providers should drive EMR usability improvements.

Of course — shouldn’t the software clinicians work every day with to improve health and save lives be adapted to fit the needs of those clinicians? You can’t offer complete freedom when you’re collecting structured data, but clinicians should be able to bend and stretch things as much as possible.

That of course, begs the question of what’s driving usability models right now, doesn’t it?  Certainly, EMR vendors care what clinicians think, but my guess is that the development roadmap has to come first far too often.

Here, let’s pretend I’ve inserted a lengthy rant as to how enterprise software companies in general just don’t connect well with their customers  – something that became painfully obvious to me when I worked for one several years ago. Suffice it to say that I doubt clinicians are as involved in vendors’ UI dev, much less feature set specs, as often as they should be.

* Usability measures should embrace not only primary care, but also specialists.

Again, this seems fairly obvious to me, but seemingly, not to federal officials, who, according to Steele, treated specialty needs as an “afterthought” when creating Meaningful Use standards.

In my opinion, it’s become fairly clear that specialty-facing systems are important, and that regulators should address such systems on their own terms. I’ve seen no sign that they’ve developed plans to do so as of yet, though. (Anyone know more than I do on this?)

* Usability shouldn’t be legislated.

For at least a couple of years, there’s been talk of the FDA’s stepping in and imposing usability rules on EMRs; observers say the rules would be akin to those they already do on medical devices and supporting software. (See more on this issue from medical device connectivity expert Tim Gee here.)

Steele, for his part, thinks such regulations would cause problems. Imposing governmental standards on EHR interface “will inevitably accommodate only a narrow range of users, leaving those with varying preferences and workflows without software to satisfy their usability requirements,” he argues.

I’d like to see Steele get his way on the first two suggestions. If EMR interfaces are driven by clinicians and take specialists into account, it’s far less likely that the government will feel obliged to impose itself upon the marketplace.

But if the industry doesn’t do a better job of partnering with clinicians, expect to see the FDA or other agencies step in.  Regulators may decide that if the industry can’t produce usable EMRs on its own, predictable, rulebound ones will do.

Today I got the announcement from SRSsoft that they have integrated their EMR software with the Medstrat PACS software. As I think about it, I’m a little surprised that I haven’t seen more integrations with PACS software. Is this because most doctors wouldn’t really use this? I know that SRSsoft does a lot of work with orthopedics and related specialties where PACS is essential. I’d love to hear what other things are happening with PACS and EMR integration.

There’s been a whole lot of discussion going on in this post on EMR and HIPAA called Why EMR Efforts Are Proceeding Slowly. The comments are an interesting read for those interested in EMR adoption. However, Jack Callahan, Executive Vice President at SRSsoft, emailed me a very passionate response to that post. I couldn’t let a passionate response like that go relatively unseen in my email inbox, so here’s his response (published with permission):

A major reason why the rate of EMR adoption is so slow is that, despite vendor claims, the actual needs and priorities of the busy, practicing provider are not built in. I’ve worked closely with three EMR companies, and am aware of more than three hundred EMR products, almost all of which, like lemmings, have decided to follow the old CCHIT design-and-development pathway over the cliff. For them, the basic design criterion involves answering the question: “How can our EMR product more effectively generate an automatic Progress Note so the doctor doesn’t have to dictate it, thereby generating cost savings to pay for the EMR?”The answer to that question always seems to be: “Enter a boatload of data from each exam.” Since most of this is entered by the provider him or herself, this is very impractical, especially for busy providers with limited panels to see patients due to surgical or other procedures that generate their primary revenue. The current products pursuing certification have enormous amounts of irrelevant functionality, require way too much data entry, and are largely unusable, especially by specialists and surgeons.

To make an analogy, the current requirements and “certification” process basically dictate that an EMR should be like this:

It should have wings so it can fly, but be shaped like a dump truck because it has to carry a lot of data. It needs to have a half-track undercarriage to provide good traction, no matter the terrain, but it must also function like a submarine in case it ends up in water; further, it must be made totally of recycled, renewable-resource materials for environmental concerns. It must be able to dig deep holes, but also be able to hover; it must be capable of high speeds, but also of changing direction easily. Of course, it should seamlessly switch from any of these modes of operation to any other mode on the fly and without unreasonable delay. Further, it must be adaptable enough to be modified to whatever purpose each user wants, but without giving up a single one of the attributes above, just in case.

Providers must purchase the product with their own funds . . . but may qualify for ARRA reimbursements if they meet certain requirements. These requirements will not be clearly spelled out in advance, however, but will become increasing complex over the five-year reimbursement period, which will end up covering only a small portion of the cost of the product. To qualify for reimbursement, providers must show “Meaningful Use” of the product in their practice—i.e., they must show they can hover, dig holes, navigate underwater, cross a swamp, carry twelve tons of cargo, fly from point A to point B, and spit wooden nickels if requested . . . all without making any mistakes. These requirements will remain in effect even if the practice only needs a simple product that goes in circles around a track.

Any vendor will be allowed to produce these products, but all products will be subject to “certification” that proves they can do all of the above, and more. Every vendor’s product must to be able to exchange parts with every other vendor’s product . . . and with any government-designated agency as well; however, the parts to be exchanged are not specified at the time the product is made. There is no standard for how complex these devices will be to operate . . . vendors will differentiate their offerings by hiring trained users to demo for providers how easy to use their product is by performing “canned,” simple maneuvers that they have spent months, or years, demoing in the past. Vendors can also “guarantee” they have passed “certification” to providers, who may assume that this means that Meaningful Use is also guaranteed; however, vendors have no accountability for Meaningful Use, only for certification. That chicken will come home to roost in 2011.

Some providers see this conundrum more clearly than others. Those are the ones resisting the enthusiastic adoption of EMRs for reasons of incentives alone. But with the marketing and PR weight of more than three hundred vendors seeking certification, with $36 billion in incentives dangling from the government Giving Tree, with the threat of potential penalties for not buying one of the monstrosities above by 2015, and with the offices of ONC and HHS pushing for adoption under administration pressure, how many bad decisions are going to be made in the coming year?

Providers will do best to not use the ARRA incentives as a criterion for adopting an EMR. They should buy an EMR because it makes sense to improve their practice . . . and they should find one that truly fits the way they practice medicine. Meaningful Use should not mean hours of entering data into a menu-driven system. Converting from paper to electronic records provides probably 70% of the benefit of adopting the right EMR, and every single practice will benefit greatly from that alone. Anything else is gravy. And there is lots of gravy to be had, with the right choice. Unfortunately, a bad choice can leave you with a very expensive, unusable, “certified” monstrosity. There are lots of them already lining the roads along the EMR highway, especially where specialists are. And there will be many more starting in 2011 if practices don’t do their homework.

One of my readers sent me an interesting comment about Physician interest in the EMR stimulus:

Personally, I was under the impression that most physicians really didn’t take the time to read such things [like this post about harmful consequences of the Government's EHR stimulus]…that they’d rather be thumbing through Golfer’s Digest or Conde Nast’s Traveler. It’s become quite clear that, when something comes along such as a government program like this that can affect their bottom-line, ears perk up and attention is paid. Now, if only more would speak up and voice their opinions to HHS…

I’ve started to see a bit of a turn myself on this site and EMR and HIPAA by physicians who aren’t too happy with the EMR stimulus. They’re starting to voice their concerns more and more. Some of them are a bit uninformed. For example, they want a “cost effective product that works” and then they ask why the VA system can’t be expanded for civilian use. I’ve talked a lot before about why the VA system has challenges, especially in ambulatory EMR. However, by starting the conversation about EMR, they’ll learn things like this.

I have a feeling that the lasting legacy of the EMR stimulus will be the increased awareness and interest in EMR. Maybe the government should never spend the $18 billion of EMR stimulus money since they’ve already gotten the desired effect of increasing interest in EMR. If after this much increased interest doctors still don’t want to implement an EMR, then maybe we shouldn’t pay them [force them] to do it.

SRSsoft, an EMR vendor, put out an interesting press release putting the lost democratic senate seat in Massachusetts with healthcare reform and EHR adoption. Here’s a quote from the press release:

“The question is not whether we need healthcare reform,” says Evan Steele, CEO, SRSsoft. “Rather, the voters voiced their concern that reform must benefit consumers and physicians, not just government, insurance companies, and vendors. This election must open the government to input from all stakeholders, and that is a good sign for the constituents of SRS—the physicians—who feel that their voice is not being heard on healthcare reform and on EHR adoption.”

Honestly, I don’t see the change in the Senate seat affecting EMR adoption at all. However, I think it will have a big impact on healthcare reform. I’ve said before that the healthcare reform has opened our eyes to the government processes in ways we’d never seen before. I think that the HITECH act has done much of the same for those of us interested in EMR legislation and rule making.

I was really intrigued by this letter sent from SRSsoft CEO, Evan Steele, to the CTO of the Obama Administration about the current administration’s EHR direction. Here’s a small excerpt from the letter posted on Health Data Management:

“I am writing to you directly, rather than posting on the FACA blog, because I am deeply concerned that the path the government is taking will inevitably lead to failure. You asked physicians for input and they answered loudly and clearly–traditional EHR technology does not work for them. Their comments are difficult to ignore.

“The government is endorsing the exact technology that has a 50% failure rate. As stated in the blog comments, physicians simply find these EHRs unusable. Of the 60 blog comments on real-world implementation experiences, 57 reported EHR failures and shortcomings–writers documented painful and costly EHR de-installations, or explained the reasons why they would not even try to implement “traditional” EHRs. There is no reason to expect outcomes to be different in the future–vendors have made no significant changes to these products to mitigate the formidable obstacles preventing their adoption. The problems cited are daunting:

* “Physicians will not purchase productivity-decreasing software–particularly now, as they face increasing demand and diminishing reimbursements. They reported productivity losses as high as 40%, and the impact did not diminish over time.

The sad part is that Evan’s letter is likely to fall on deaf ears. First, because Aneesh Chopra probably doesn’t care much about EMR software. Second, a letter from an EMR vendor who wants the rules changed to get better access to the $36.3 billion in EMR stimulus money for his customers is likely to be seen as a political move. Even if Evan is correct with what he’s saying, that doesn’t mean that Aneesh will realize it. Third, is it too late? The HITECH legislation is past. Can HHS really make that much of a difference at this point? Sadly, I don’t think Evan we’ll feel any better 2 years from now when he says, “I told you so.”

This is a part of a post on the SRSsoft website. I am a fan of SRSsoft because I think they have it right when they focus on “provider productivity” as a key component of any “good” EMR. See the link below to see the whole blog post, but basically, they went to Washington to advocate for EMRs which improve productivity and enhance the physician-patient relationship.

This is an excerpt from the post:

The signers of this petition are not all SRS clients. Other providers reached out to us and asked that we stand up for them as well. SRS users or not, they are passionate about EHRs, and they speak from positive and negative experience with a variety of EHR products. Three fundamental themes dominated:

*Physicians will not adopt technology that compromises their productivity,
*They will not become data entry clerks, and
*They will not jeopardize the physician-patient relationship.
*No financial incentives or penalties will persuade these physicians to take actions they deem detrimental, or not valuable, to their practices.

Bottom line is that most physicians (if they are smart) will not be induced by incentive or penalties to take on an EMR unless the EMR makes them more productive! I agree with this. Washington needs to make the definition of “meaningful use” and “certified” flexible enough to encompass EMRs that are innovative and enhance our ability to be great doctors and provide excellent care.

SRSsoft EMR emphasizes speed, efficiency and provider productivity. If your EMR slows you down and makes you less productive, you will lose money and there will be no ROI. More importantly your income will diminish because you will be seeing fewer patients per hour! The $44,000 to $64,000 offered in government incentives (over 5 years) will be insignificant compared to the income you lose due to decreased productivity.

What are your thoughts about provider productivity? For complete post from SRSsoft’s CEO go to: http://blog.srssoft.com/?p=496

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

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

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

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