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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?

One Hundred Percent of Doctors and their offices use Practice Management Systems (PMS). Only 3% user “fully functional” EMR Systems. Why only 3% with EMRs and 100% with PM Systems?

The government is going to pay us $44,000 per doctor to use an EMR. They are going to give us a 2% Medicare bonus and other pay-for-performance incentives and they are going to penalize us in the future if we don’t use EMRs. In addition, hospitals are allowed to pay 85% of the cost of the software and training. Will all this money get us the use EMR? Can we be bought? Is it in our interest to use EMRs?

The CEO of SRSsoft tells us that this type of money is not significant if the EMR makes you less productive and less efficient. For example, if you bill $500,000 per year and your EMR makes you 10% less efficient, you lose $50,000 per year!

I agree with this CEO. We (doctors) will not embrace EMR systems until they are usable and they add value! “Usability is the effectiveness, efficiency, and satisfaction with which the intended users can achieve their tasks in the intended context of product use.” This definition comes from NIST, ISO and UserCentricity. Adding value means that it makes our jobs more enjoyable, shortens our work day or helps us provide better care.

Doctors use practice management systems because they are usable and they add value. Doctors do not use EMR Systems because most DO NOT add value and they are not usable. There are so many bad EMR systems on the market that the stench and confusion has caused many doctors to not even look (they ask their colleagues who have EMRs and these colleagues say “stay away, it is not worth the cost, aggravation and problems”).

I believe that there are some very good EMRs on the market. The challenge is to find them and promote them. If we (doctors) can find the good EMRs, word will spread and implementation will happen very rapidly!