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EMRs, Small Business and Universal Coverage

Posted on July 28, 2009 I Written By

I turned on the radio on Monday and they were talking about Healthcare again. Universal coverage, the August recess, the “blue dog” democrats.

I keep thinking about how EMRs fit into all of this. Obama thinks that EMRs are going to make care better, more efficient and less costly. I think he is right about the first two (if we install EMRs that are usable and bring value to doctors and patients), but not necessarily about the third. EMRs may not reduce costs!

As Obama takes our economy (and our healthcare system) away from the small business model to the big government/big business model, I wonder how EMRs fit into all this. Investing in an EMR is a big deal for most physicians because we are a small business that provides medical care. Spending hundreds of thousands of dollars on an EMR which may not bring return on investment (ROI) while potentially reducing our productivity is a big risk. At the same time, if reimbursement are reduced or the system becomes Universal, the stakes are higher and the risks are greater.

Everyone (individuals and small business) is struggling with our current economy. Small businesses are at risk (many are closing their doors). Physicians are working hard to pay the bills, make payroll and have a little left over to take home to the family. The EMR issue has to be handled correctly or it could have dramatic effects on our healthcare system. The EMRs have to be effective and efficient. Doctors have to like them and be satisfied with their utility and performance. EMRs have to help us take care of patients more effectively and efficiently. Anything less than this throws more sand into the cogs of the healthcare machinery and amplifies the risks of all the other changes occurring at this time.

What is “Meaningful Use”, What EMRs should be “Certified” and Who should do the Certifying

Posted on July 27, 2009 I Written By

Because of all the money being thrown at doctors and hospitals as part of the HITECH (Health Information Technology for Economic & Clinical Health) Act, a component of the ARRA (American Recovery and Reinvestment Act), it becomes important to use certified EMRs in a meaningful way.

It has always been important to use EMRs in a meaningful way, but now you can get paid ($44,000 per physician) if you jump through hoops created by organizations like CCHIT which is the Certification Commission for Healthcare Information Technology, who want to make money for their executives and suppress competition for their top clients. The government has put the wolves in charge of guarding the hen house. Diversity, choice and competition have taken a back seat to self-serving regulation based on big business payoff of our government at its highest level (the big EMR companies have bought Obama). This is truly breathtaking and incredible (see BusinessWeek May 4, 2009, page 31-37)! The best way to stunt the development of any system is to suppress diversity, choice and competition by putting the rich and powerful in charge. The people in charge want to make more money, they don’t want better EMRs and they don’t want what is best for our healthcare system.

Today’s blog is going to be a little different. I am not going to comment on the present criteria used for CCHIT certification and I am not going to comment on the current state of the “meaningful use” definition. I KNOW what “meaningful use” is. I am a doctor, I have an EMR … I know “meaningful use” when I see it. Walks like a duck, quacks like a duck, looks like a duck. All doctors KNOW intuitively what “meaningful use” is.

I am not going to comment on the specifics of CCHIT Certification Criteria because I KNOW it is not optimal. Tear it all down and let’s start from scratch. It may have served a purpose in the past to move the industry forward, but it has now become a problem. It inhibits innovation, diversity and choice. It costs too much, it is too complex and many very good EMRs are not CCHIT certified. Company’s are wasting their time, money and effort to get certified rather than improving their EMR product! CCHIT’s primary purpose now seems to be self-preservation at any cost. Their executives want to preserve their six figure incomes at any cost.

Instead of commenting on what others have said about these two issues, I am just going to tell you what I think … I am going to keep it simple.

Any EMR that can be used in a meaningful manner should be certified. Period. End of the certification problem. My definition of meaningful use is so simple and so intuitive that certifying an EMR becomes very easy. So easy that you don’t need to pay much money and you don’t need an organization like CCHIT. You can hire a CPA or an Accountant to do the certifying.

Any EMR should be certified if it can do everything listed below. If it can do these tasks, it is being used in a meaningful manner and thus satisfies the “meaningful use” requirement.

What an EMR must do:
●Document a Progress Note
●Store, Index and Provide access to Lab Results, Test Results, Hospital Reports and Consultation Reports
●Store and Track Wellness information for Chronic Conditions like Diabetes (Fasting Blood Sugars, HgAICs, Eye Exams, Kidney Tests and Foot Exams) and Coronary Artery Disease (Blood Pressure, Cholesterol, EKGs, Stress Tests, Echocardiograms, Catheterizations, Cardiac Consultations).
●Store and Track Health Maintenance Information for Routine Care of Adults and Children (Flu Shots, Pneumonia Shots, Immunizations, Mammograms, Pap Tests, PSA, Colonoscopies, Bone Density Tests)
●Write Prescriptions
●Write Orders
●Help Select Diagnosis Codes (ICD-9 and CPT Codes)
●Help Select Level of Care Codes (Evaluation & Management (E&M) Codes)
●Perform Scheduling, Billing and Intra office Messaging OR Interface with a Practice Management System
●Collect and Report data for Quality Improvement Activities and Pay-for-Performance Activities
●Connect with Regional Health Information Exchange Platforms (HIE Platforms) AND be able to Import and Export Data in the Continuity of Care (CCR) or CCD Format

If an EMR can do the above tasks then it is being used in a meaningful manner and it should be certified. My background is Internal Medicine, so there may be adjustments that are need for certain specialties. Some may feel that I should include a patient portal and clinical decision support in the above criteria.

Let’s not overcomplicate this EMR thing. We want doctors using an EMR and we want companies coming up with better EMRs which help doctors provide better, more efficient care at a lower cost. The only way to achieve these goals is to let the market place select the best EMRs. In order to do this, you need innovation, variety and choice. You have to nurture and support small companies. We have to encourage people to get into the EMR business rather than create barriers to entry. Using CCHIT certification and possibly a complicated definition of “meaningful use” we risk inhibiting innovation by snuffing out new and small companies with regulations that are not practical, helpful or wise.

CALLING ALL DOCTORS! EMR Software Opinions Wanted

Posted on July 24, 2009 I Written By

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?

EMR Software, Hospital Systems and Their Physician Practices

Posted on July 23, 2009 I Written By

Hospitals are buying EMR systems for the Physician Groups that they own and they are allowed to pay 85% of the software and training costs for their independent physicians (physicians that they do not employ, but who refer patients to their hospital).

They are doing this for a number of reasons. It will improve communication for better and more efficient care and it will “connect” these physicians to that hospital (in multiple ways). Keeping the referral pipeline flowing is very important to hospital systems. This type of arrangement makes it more difficult for doctors to move their patients to other hospital systems and it builds loyalty.

Most hospitals are picking ONE system for their employed physicians and then they are going to offer to pay 85% IF independent physicians use this ONE system.

Although well intentioned (hospitals are trying hard to pick the best system for their doctors), I believe this approach is doomed to fail and will cause hard feelings and other problems.

Hospitals want all their doctors on one EMR system because of volume discounts and because they believe in maximal connectivity. Again, their intentions are logical and well-founded, but miss the mark.

Why will it fail? Because different doctors and different physician groups have different needs, different styles and different preferences. Doctors also need to be “masters of their own fate”, if they fail, they need to “own” the problem. In addition, hospital systems are only considering EMRs from the “big EMR companies” because they believe that “connectivity” trumps “usability”. When you limit your options to the “big EMR companies” you are choosing some of the least usable systems on the market.

Doctors need choice! They need to make the final decision on the system they purchase. Only they can find the best system for their practice and their practice style. One size does not fit all.

When the doctors become unhappy with the EMR software that their hospital chose for them (not usable, difficult to learn, decreases their productivity), they are going to become unhappy with that hospital system and their administrators. Since failure to implement EMR software is very high, we know this is going to happen not uncommonly. I anticipate lots of problems a few years from now. Let’s see how this plays out.

I am hoping that hospital administrators are smart enough to stay out of this EMR software trap. Give doctors a choice. Give doctors options. Don’t believe the big EMR company salespeople who tell you that you all need to be on the same system.

When will Doctors Enthusiastically Get and Use EMR Software and EMR Systems?

Posted on July 22, 2009 I Written By

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!

Inertia in Healthcare Is Sometimes a Good Thing

Posted on July 21, 2009 I Written By

President Barack Obama is defending his relentless campaign for a health care bill before Congress’s August recess, saying “the default in Washington is inaction and inertia.”

Mr. Obama, there is a good reason for inertia. It protects complex systems which have evolved over time from dramatic change which can be very disruptive and threaten the very survival of the system. Inertia moderates change so that change can be accomplished slowly and successfully. Inertia is sometimes a good thing. In the case of healthcare reform, this inertia might save our healthcare system.

Improving our healthcare system is an important project. This cannot be done in 3 months by politicians and bureaucrats who are not expert or experienced in the ways of healthcare. The system must evolve slowly, thoughtfully and carefully.

The goal should NOT be universal coverage at the expense of everything else! Universal coverage is a worthy goal, but there are other things which are more important like quality of care, cost of care, ability to access care, innovation and properly aligned incentives. Universal coverage puts EVERYTHING else at risk and therefore we need to pause, take a deep breath and figure out how we are going to improve our health system without ruining it and putting our whole economy at risk.

The experiment in Massachusetts has been a disaster. It has achieved the goal of universal coverage but the cost of care has gone up and access to care is terrible (not enough providers). Doctors are miserable, not making any money and they are leaving the state. Let’s look very closely at Massachusetts before we duplicate this disaster at the national level!

A Patchwork Quilt of Unique EMR Software

Posted on July 20, 2009 I Written By

We keep hearing about the Big National Data Bank for Healthcare Information. The thought is that you need a big data bank so everyone’s health information is available anywhere/anytime. This type of personal health information repository has many problems. First it is complex and expensive to set up and maintain. Second there are very significant and well-founded privacy concerns. And finally, this large, complex electronic structure may not be needed … it might even be counterproductive!

Is there another way to transport patient health data from one platform to another (so it can go from one EMR to another), so that healthcare providers, anywhere/anytime can provide fully informed care for individual patients which would be less expensive and higher in quality?

I think the answer is YES!

There are standard data exchange platforms currently being used which can help us all share “meaningful” personal health information. They are called the Continuity of Care Record (CCR), CCD and HL7. For more information on these platforms, I suggest you read Brian Klepper’s blog post. This blog gave me great insight into this connectivity issue.

In addition to obviating the need for a big data bank, these data exchange platforms make it possible for small, innovative EMR companies to compete and survive in the “EMR Jungle”. By allowing for diversity and encouraging innovation, we will end up with better EMR software. In addition, physicians will be able to pick EMRs that suit their practice style and can make them more efficient, productive and better doctors. I think we need a patchwork quilt of unique EMRs that are all well connected rather than a few big standard lemming EMRs that are totally connected by “big brother” or “big business”.

What are your thoughts on this topic?

Big Government, Healthcare IT, Our Healthcare System and the Economy

Posted on July 17, 2009 I Written By

There are a couple things going on in this country which are troubling. Two of them have to do with healthcare and the third has to do with our overall economy which is closely linked to healthcare.

Government is getting too involved with healthcare. First, they are rushing to mandate information technology (IT) which is not “ready for prime time”. Second, they are going to set up a government option for healthcare which will be subsidized by our tax dollars. This option will drive other insurance companies out of business (you can’t compete with a significantly subsidized competitor). There will then be a one payer system so we will no longer have choice. This system will be designed and run by government beurocrates (which I am not excited about) who we will be supporting through our tax dollars (higher taxes on everyone). Healthcare will be more expensive and less effective (See Medical Economics July 10, 2009, Critical Mass) AND this system will have a negative effect on small business and big business and our economy. Finally doctors will be affected in all sorts of ways (see Medical Economics July 10, 2009, Top-down, bottom-up, and medicine in the middle).

As we watch Obama and his advisors change our basic healthcare system and our basic economic system (from a small business model to a big government model), everyone should take some time to read Atlas Shrugged by Ayn Rand. The book is very long, so read the Cliff Notes!

What are your thoughts on all the changes going on right now, from the changes in our healthcare system to the mandates for electronic medical records. Who is going to pay for all this? Who is going to implement all of this? Is it going to work? Are we doing a big experiment (with our whole healthcare system and our whole economy) without doing smaller experiments to see what will happen?