For those who might have wondered I live in Las Vegas, NV. I must admit that despite living in Nevada I haven’t been that involved in the healthcare IT community before now. I guess I see this blog as more of a national and international thing and so I haven’t been as interested in what’s happening in Nevada. Plus, I didn’t really have the time to really spend their either other than the specific projects I was working on.

I’m not sure exactly why, but I recently got connected with the local Nevada chapter of HIMSS and actually went to a little lunch meeting with them. It was interesting to go and hear a local meeting from what I guess amounts to my neighbors doing a lot of the same things I’m doing. Granted, they had some misplaced views about EHR certification amongst other things, but that was really to be expected. However, over all I found a bunch of really smart people that were experiencing a lot of the same things I was experiencing.

In a kind of ironic way, I also got a call from a colleague of mine talking about the Southern Nevada Medical Industry Coalition (SNMIC) and more specifically their Electronic Health Records Initiative. Sounds like they’re working on some pretty interesting things for which I may be apart of helping to educate people on EHR.

I guess the point of this nice long rambling post on a Friday is to encourage readers of this blog to reach out to their local EHR community. It’s an interesting experience and worth spending a little time cultivating. Also, I’d be interested in meeting other people who work on EHR in Nevada. We can share our EHR “war stories” over lunch.

I was reading through a short article entitled “CCHIT TASK FORCE TO FOCUS ON STIMULUS PACKAGE REQUIREMENTS” which is actually a bit misplaced since the article really seems to talk about the CCHIT Task Force for Long Term and Post Acute Care, but I digress.

The thing that drew my attention was just reading through the process by which CCHIT puts together their criteria using task forces. I believe a number of people on my twitter feed are on or lead some of these CCHIT EHR task forces. I’d be interested to have a nice writeup from some of them on what it’s like to be on a CCHIT task force. How does it work? What’s the dynamic? If you’re willing to share, I’d love to hear more in the comments or drop me a note on my contact page.

I also was trying to think of other cases where a task force like approach worked for certifying software. I couldn’t really think of any. However, I couldn’t think of that many software certifications either. What I have seen work to a certain extent is large IT vendors that come together in some sort of organization to establish a standard for communicating. This is something that I wish would happen with a number of EHR vendors. It’s not something that will really help an EHR vendors bottom line, but it’s the right thing to do and that has its own benefits.

Blumenthal gave a recent speech at the HIT Symposium at MIT. I must admit that as I’ve heard Blumenthal speak I’ve grown pretty fond of what he’s trying to do within the bounds of what’s available to him. Here’s a quick look at some things he said with my thoughts.

“I found that (information technology) changed me as a physician. I thought it was going to change practice. That was 10 years ago,” Blumenthal said. “I think that reality will be realized within a few years.”

I’ve heard Blumenthal say this before. I guess given the number of speeches he gives it’s ok for him to repeat on occasion. That said, this is something that physicians hate to hear, but need to hear it. An EMR will change the way you practice. It won’t change the fact that you are going to give quality care to your patient. It won’t remove the need for all your training and intellect. However, information technology does become the heart of a practice when you implement an EMR. It’s nice that Blumenthal is willing to just state the facts.

More Blumenthal…

“If you look at the calendar and think about the institutions we need to create by 2011, it is a truly daunting prospect,” Blumenthal said. “And in some ways, if we started a year ago, we’d still be late.”

I’ve been talking about a delay in EMR stimulus money for a while. No doubt it is a daunting task. Luckily, I’m one that believes in the BHAG (Big Hairy Audacious Goal) and it seems like Blumenthal does too. Considering the government’s spending billions of dollars, you better think that way. Let’s just hope we don’t spend all that money and actually regress.

Blumenthal acknowledged other challenges facing the ONC, such as addressing the needs of small providers, privacy and security concerns and the lack of attention the current legislation pays to providers of long-term care, home care and hospices. ONC hopes to include those providers later, he said.

“We need that connection, but very frankly we don’t have the resources or the authority in this legislation to do what we need to do in that sector,” he said.

Nice to see Blumenthal acknowledge some of their weaknesses. I’ve been an advocate for the small providers for a long time. I don’t think the EMR stimulus money is right for small practices for the most part. However, I do think an EMR is right for small practices. They can still provide benefits without the EMR stimulus money.

Someone sent me this article (you’ll have to subscribe to see the full article) on EMR use and the liability that comes with using an EMR. I must admit that having covered EMR for a number of years, I’m surprised that the malpractice side of an EMR hasn’t gotten more coverage. Certainly there are potential malpractice risks and benefits to using an EMR. This section of the article pretty well sums it all up:

An estimated 85,000 medical lawsuits are filed annually, which include those against hospitals and individual physicians. One of the highly-touted benefits of electronic medical records (EMRs) is the potential to help prevent malpractice incidents and medical errors. By providing better documentation, automatically checking for medication errors and drug interactions, providing failsafe systems to track test results and follow-up with patients, EMRs can dramatically reduce the risk of malpractice.

While the benefits of EMRs are far greater than the cons, no road is without stumbling blocks. A physician who is not careful when using the EMR could increase his malpractice liability.

The article goes on to list the following malpractice risks of using an EHR:

• Too much information
• Wrong Template can Bollix Up the Chart
• Changing the Standard of Care
• Attention to the Patient

Malpractice is definitely something to make sure you consider when implementing an EMR to avoid problems down the road.

A couple weeks ago I attended the HIMSS virtual conference. I must admit that I mostly wanted to attend to interact with people. One of the more interesting things I found while interacting with some of the vendors was the price that the various vendors paid to be able to exhibit at the HIMSS virtual conference. I should have known the price would be high, but it was quite astonishing to me.

With one vendor in particular we talked about the price they paid and my quick back of the paper calculation showed that for the same price of having a “second floor” exhibit at the HIMSS virtual conference that vendor could advertise on EMR and HIPAA for about three years. That’s right. 2 days at a virtual conference or 3 years on a website targeted to EMR.

Yes, this post is kind of a way to talk about advertising on EMR and HIPAA. However, I think it also gives some interesting perspective for EMR and EHR vendors that are trying to market their product. Certainly there are lots of channels that could be used, but I think advertising on this site is one of them.

I must admit that the pricing HIMSS is charging has made me think about what I charge for advertising on EMR and HIPAA. However, I don’t see me drastically changing my prices. My goal with advertisers has always been to try and provide them value for the dollars their spending. I figure if I do that, then they’ll keep renewing and life will be good. Luckily, they have been renewing and life is good.

Now I just wonder how many years of advertising an EMR vendor would get compared to the cost of a booth at the HIMSS annual conference. Reminds me of the open source EMR Medsphere Bus picture from HIMSS next to the Cerner Semi Truck.

One of my regular readers, sent me the following email about the availability of IT help for those implementing an electronic medical record (EMR).

If my conjecture about the mad rush for good quality IT help is correct, then I wonder if physicians will have to choose between experienced HIT contractors that have long waiting lists and may be overwhelmed with demand (particularly if they get greedy about taking on too many clients or have trouble scaling) or try to find a good but inexperienced firm that will be responsive.

Could be an interesting dilemma?

There’s no doubt that a physician’s IT support can sink an EMR implementation just as easily as a poor EMR vendor. I wonder how many failed EMR implementations should be credited to the IT people over the EMR vendors. I still give the lions share of responsibility for failed EMR implementations to the EMR vendors, but a large number are still thanks to poor IT support.

So, yes it is quite the dilemma. Either it’s going to slow the adoption rate of EMR or inexperienced IT people are going to cause lots of headaches for those implementing an EMR. I have a feeling we’ll have more of the later. The reasoning is simple. How do doctors know who is quality IT help and who is not? Answer: most don’t. I’ll have to think about ways in which I can help physicians solve this problem.

I personally believe that many good quality IT help companies will have trouble scaling as is described above. I know there are companies that have done this relatively well, but I personally think that scaling good help (basically people) is the hardest thing for any company to do.

Today’s the final day for providing feedback on meaningful use to ONC. I find it a little bit ironic that as ONC and healthcare IT in general is stirring about the words “meaningful use” I find a survey by Nuance that shows that 90% of doctors are “concerned” about the usability of EHR.

This figure probably isn’t surprising to any of you out there that have worked in the EHR industry for a while. The usability of the EHR has been one of the big barriers to EHR implementation for quite some time.

I hope that no one is naive enough to think that requiring a bunch of features and reports to show “meaningful use” or “certified EHR” that we’re somehow going to make EHR software more usable. In fact, the opposite may be more likely.

I can just see in my minds eye a bunch of EHR programmers slapping in some half baked code in order to satisfy some “meaningful use” or “certified EHR” criteria. Yes, it probably will meet the criteria, but at what cost to the end user? I’ve very rarely known quickly created software to be very usable. Understanding and implementing usable software takes thoughtful planning to execute correctly. Someone who understands how to simplify the process while still implementing the necessary features.

In the rat race for EHR stimulus money, I predict that usability of EHR systems will actually decline rather than improve.

I’d been meaning to post this when the meaningful use document came out, but didn’t get around to it until now. ONC has asked for public comment on the preliminary definition of “meaningful use” as presented by the HIT policy Committee (see the Meaningful Use Matrix). Submissions are due by 5 pm est June 26, 2009, and should be no more than 2,000 words in length (per the HHS HIT website).

I encourage everyone involved in Helathcare IT to submit their thoughts on meaningful use. I’m a big believer in leveraging the knowledge of crowds to make something better. I believe that if you amass enough smart people on something, you usually get a pretty good result. Assuming that they listen.

I’d also certainly welcome people to post their submissions in the comment of this post if it’s something you don’t mind making public. I think it could be really valuable to have all the various submissions aggregated in one spot for everyone to review and consider.

Here’s the other details for meaningful use comment submission from the HHS website for those interested in submitting (nice that they have an electronic option):
Electronic responses to the draft description of Meaningful Use are preferred and should be addressed to:
MeaningfulUse@hhs.gov
With the subject line “Meaningful Use”

Written comments may also be submitted to:
Office of the National Coordinator for Health Information Technology
200 Independence Ave, SW
Suite 729D
Washington, DC 20201
Attention: HIT Policy Committee Meaningful Use Comments

As I first looked over the meaningful use matrix (PDF) that was created by the HIT policy committee I thought that the requirements listed were reasonable and doable. Then, I realized that I was only looking at the first page of a seven page document.

For now, I’ve focused on looking at the 2011 objectives. I wanted to really focus on it since that’s the bar with the most stringent timeline for those wanting to get the EHR stimulus money from ARRA.

I’ll talk in more detail about the various items in a future post. However, as I look through the list of objectives to show meaningful use for 2011, I don’t think any of them sound unreasonable. On their own, each objective listed seems to be something that is completely doable. I might question why some are on the list, but I don’t see any of them individually as too much to accomplish in that time frame.

The problem is that the 22 meaningful use 2011 objectives as a collective whole would be daunting for any practice. I previously wrote about the challenge hospitals face implementing an EHR quickly, but I think this list of objectives would be hard for a practice of any size. I guess some of the reporting could be centralized for a hospital system and save them some time. For a small office, they’d have to do all the reporting themselves and that could be time consuming. No wonder David Blumenthal, ONC head, sent the meaningful use matrix back to the HIT Policy Committee.

I see two other major problems I see with the meaningful use matrix. First, some of the requirements don’t even have established standards yet. Sure, it’s a nice concept to say that doctors should have to “exchange key clinical information.” That’s kind of one of the points of the legislation. Unfortunately, we don’t have any real established standard for sharing key clinical information between providers. CCR seems to have some merit, but is far from becoming THE standard for sharing clinical information. Seems like we’re getting cart before the horse when we ask people to do something for which there is no established and recognized standard.

Second, how is HHS/ONC going to measure accomplishment of these objectives? There not going to go around to each clinic to verify that they actually have an “active medication list” or that they “incorporate lab results in the EHR.” Maybe it’s just the practical side of me. It’s nice to have these objectives, but if we don’t have a way to meaningfully measure that the objectives are being accomplished then it will be abused. I think ONC and HHS might be responsible for deciding how to do this, but I think it would be naive of the HIT policy committee to make these recommendations without good ways to measure them.

Many people have been arguing that it’s an easier process for hospitals to be able to justify the implementation of an EHR thanks to the new EHR stimulus money. Even more important might be the 5% penalty for not implementing an EHR.

There’s no doubt that there’s a lot of money at stake in a large hospital system that has 100+ practices. You can do the math: number of providers x $44,000 = A lot of money. However you also have to add to that amount the penalties which is basically: Medcare reimbursement x 5% = Even more money.

I’m certain that every hospital in the US is keeping a close eye on these developments. Even large group practices have some of the same financial equations with just a little bit smaller scale.

What I think most people are forgetting is that there’s a reason most of these hospitals haven’t implemented an EHR. It’s not a simple task. We’re talking about getting hundreds or providers with even a larger number of workflows to agree on an EHR system and then implement it across multiple specialties.

I’ve talked about my experience before visiting what I believe is one of the largest EHR implementations in the US of its kind. They have 100 multi specialty clinics and have been working on their EHR implementation for at least 3 years (if my memory serves me right) when I met with them. After all these years of implementing they were still at about 25% implementation.

Not only had they only been able to implement that small percentage of practices, but they were also just starting to butt up against some major resistance based on the first 25% of practices implemented. Add on top of that the EHR vendor’s ability to support such a large implementation and they were running into some real slow downs.

Now I think this practice had made some real progress and had some pretty strong leadership at the top to even get where they were at the time. However, my point is that even with the best of intentions, these large hospital systems are going to have a major major challenge trying to implement such a large number of EHR in order to receive the ARRA money. Certainly there’s a lot of money at stake, but there’s also certain laws of time frames that makes this an almost impossible task to accomplish in the ARRA timeline.

The crazy thing is I haven’t even really talked about meaningful use in this post. I’m just talking about implementing the EHR and getting doctors to use it. Then, what effort will be required on top of that to show meaningful use of an EHR?