As is now tradition. Some EMR and EHR tweets that are of interest this weekend.

@linejboise
James Lineberger
2011 EHR Adoption Rates #EHR #EMR #Health IT bit.ly/uQS7VP

They put EHR adoption at about 50%. Remember these numbers are from the CDC. I think they’re being generous. I’d still put adoption at about 25-30%

HHS extends MU Stage 2 deadline to spur faster EMR adoption | Healthcare IT News: http://www.healthcareitnews.com/news/hhs-extends-mu-stage-2-deadline-spur-faster-emr-adoption

I know I wrote about this before. Now it’s official. So, I guess there is some small advantage to showing meaningful use in 2011 instead of waiting until 2012. Although, not much.

Now a great series of tweets that discuss the bain of many IT people’s existence: IE

@chukwumaonyeije
C. Onyeije, M.D. MFM
I still can’t believe why ANYONE would use Internet Explorer (unless they were forced to by IT geeks at gunpoint…)

@faisal_q
Faisal Qureshi
@chukwumaonyeije …or EMR vendors that use the IE engine within their own app

@chukwumaonyeije
C. Onyeije, M.D. MFM
@faisal_q Funny that you should mention… I’m working with a hospital based EMR that goes NUTS in Chrome. #EMRFail …

The internet would be a lot better if IE weren’t around. Yes, I’m a huge Chrome fan myself.

I’m currently on the long flight from Las Vegas to New York City. The early flight time and long flight remind me why I prefer to just stay in Las Vegas with the occasional west coast trip, but I digress. In order to not lose an entire day of work on the airplane, I spent far too much for the overpriced internet service on my flight. As I’m traveling at 30,000 feet, it’s amazing to me that I’m connected nearly as good as when I’m sitting at home. Sure, in flight internet has been around for quite a while, but it still amazes me. What will amaze me even more is when the internet is free on every flight. Maybe pharma ads could pay for this too.

While experiencing this amazing connectivity, I can’t help but think of how poor so much of the connectivity in healthcare is. That’s right. We can find a way to offer internet connectivity at 30,000 feet in an aircraft moving hundreds of miles per hour and yet we can’t get connectivity to rural hospitals and other healthcare locations?

Plus, even speaking more broadly, I can access all of my normal services from an airplane, but for some reason I have no way to connect all of my healthcare data together.

Those in the industry realize the problems. The challenge of connecting all of our healthcare data from the various EHR (or maybe in this case EMR is appropriate) data silos is an academic exercise that’s easily accomplished. Hit any of the interoperability showcases at HIMSS or other healthcare IT events and you’ll see EHR software vendors communicating with each other and sharing data. Why then can’t we make this a reality?

The challenges are still the same they’ve been for a long time now: funding and politics.

I still cringe to think of the missed opportunity that ARRA and the HITECH Act could have provided in this regard. Instead of incentivizing use of an EMR, they should have and could have incentivized interoperability of healthcare data. The great part is that you’re not going to start exchanging data in healthcare without an EHR so you’d be getting more EHR software adopted and interoperability. Water under a bridge now I guess, but it keeps eating at me.

My biggest hope now is that a grass roots movement will form that will drive what we should be doing anyway. Everyone knows and understands the benefits to healthcare and the patient of exchanging healthcare data. It’s easy to make the case for how patient care improves and how duplicate costs are avoided. We need more people that are willing to hop on board interoperability of healthcare data cause it’s the right thing to do. Sure, we need to do it in a smart and reasonable way, but the ROI of healthcare data exchange goes well beyond dollars and cents. This ROI can’t be put on a spreadsheet, but instead will help us all sleep better at night.

Are there any movements like this out there? I can’t say I’ve seen any, but I’d love to see one. Then, we’d have a real beacon community that’s set on a hill because it earned and deserved the recognition as opposed to beacon communities paid for by tax payers.

Side Note: I’ll be in NYC this week at the Digital Health Conference and at the mHealth Summit in DC next week. I’m already planning to meet a number of my readers at these events, but I’d love to meet more.

One of the really interesting things I noted while attending the NextGen user group meeting had to do with the move to SaaS based EHR and other SaaS based EHR software. I partially mentioned this in the write up I did at the conference, including a tweet where I talk about how Scott Decker really pushed the idea of NextGen making the move into the SaaS based software world.

I think there’s little doubt that NextGen sees the value of SaaS based software. I think they see the convenience to doctors of not having to manage a server. Most importantly, I think they see the value of not having the healthcare data stored in EHR in silos.

One thing that Scott Decker mentioned in his keynote was improving their coding rules engine based on the feedback and experience across all of their SaaS based EHR users. I found this really intriguing since it highlighted some of the challenges and limitations of the client server EHR model that’s so prevalent in healthcare.

After hearing these comments about NextGen’s move towards more and more SaaS based software, I wondered what users at the meeting thought about the move by NextGen to SaaS EHR. The nice part of a user group meeting is I had a chance to talk to a number of them.

One company I talked to said basically, “We have 30 Citrix servers in our NextGen EHR installation. That’s a huge investment we’ve made and I don’t see us changing that any time soon.” They’ve got an interesting point. There’s a lot of money invested in training, equipment, software, and general understanding of the current client server EHR installs that NextGen employs (or is it employed?) for its large EHR customers.

It’s quite a stark contrast to consider this entrenched client server user base that is unlikely to change even if NextGen’s direction is headed towards SaaS EHR software. To be completely honest, I’m not exactly sure how this “conflict” is going to play out.

One of my all time favorite posts I’ve done was called “Develop Your Own EMR….Are you Crazy?” Hard to believe that was back in May of 2006. I should go back and check out the content of that post, but the title still rings very true to me. Of course, every entrepreneur that I know is a little bit crazy, so it should come as no surprised that I’m hearing all the time about new EMR software getting ready to hit the market.

Today’s encounter has to be one of the most unique. I was going to church in another state (visiting family for the Holidays) and I ran into one of my high school friends at church. We caught up and I learned that he’s the owner of a software development company. Then, as he learned what I was doing he just mentioned off hand that they were developing an EMR.

After I picked myself up off the floor, the meeting at church started so I didn’t really get a chance to talk to him. Since he’s my friend on Facebook (you know, a real friend that I know in real life type of Facebook friend), I sent him a message and hopefully we can connect. I’m really intrigued that his software development house is doing an EMR for someone. Obviously, now I have a ton of questions for him about the project. He did say before the meeting started that “it’s a BIG project.”

Of course, the message here is that there are a lot of people out there that are crazy (no offense intended) enough to start building another EMR. The problem is that there are so many doctors that are dissatisfied with the EMR software that’s out there, I’m sure until that’s resolved we’ll see more and more EMR software entrants. Oh, if only these brave souls knew what they were getting themselves into. I guess maybe that’s the beauty and key to entrepreneurship and why I love it so much.

In many of our Meaningful Use Monday series we focused on a lot of the details around the meaningful use regulations. In this post I want to highlight one of the strategies that I’ve seen a bunch of EHR vendors and other EHR related companies employing to meet Meaningful Use. It’s an interesting concept that will be exciting to see play out.

The idea is what many are calling clinical data abstraction. I’ve actually heard some people refer to it as other names as well, but clinical data abstraction is the one that I like most.

I’ve seen two main types of clinical data abstraction. One is the automated clinical data abstraction. The other is manual clinical data abstraction. The first type is where your computer or server goes through the clinical content and using some combination of natural language processing (NLP) or other technology it identifies the important clinical data elements in a narrative passage. The second type is where a trained medical professional pulls out the various clinical data elements.

I asked one vendor that is working on clinical data abstraction whether they thought that the automated, computer generated clinical abstraction would be the predominate means or whether some manual abstraction will always be necessary. They were confident that we could get there with the automated computer abstraction of the clinical data. I’m not so confident. I think like transcription the computer could help speed up the abstraction, but there might still need to be someone who checks and verifies the data abstraction.

Why does this matter for meaningful use?
One of the challenges for meaningful use is that it really wants to know that you’ve documented certain discrete data elements. It’s not enough for you to just document the smoking status in a narrative paragraph. You have to not only document the smoking status, but your EMR has to have a way to report that you have documented the various meaningful use measures. In comes clinical data abstraction.

Proponents of clinical data abstraction argue that clinical data abstraction provides the best of both worlds: narrative with discrete data elements. It’s an interesting argument to make since many doctors love to see and read the narrative. However, all indications are that we need discrete data elements in order to improve patient care and see some of the other benefits of capturing all this healthcare data. In fact, the future Smart EMR that I wrote about before won’t be possible without these discrete healthcare data elements.

So far I believe that most people who have shown meaningful use haven’t used clinical data abstraction to meet the various meaningful use measures. Although, it’s an intriguing story to tell and could be an interesting way for doctors to meet meaningful use while minimizing changes to their workflow.

Side Note: Clinical data abstraction is also becoming popular when scanning old paper charts into your EHR. Although, that’s a topic for a future post.

I always love when people talk about the paperless medical office. It’s as if they believe that after implementing an EMR they will no longer have to have paper in the office. Turns out, EMR software can print out a lot of paper if you’re not careful.

While ePrescribing is on the horizon in many places, the harsh reality is that many still have to print out prescriptions. Add in the requirements around prescribing controlled substances and in almost every state doctors using an EMR are still having to print out prescriptions.

In my clinic, it always felt wrong to print out an entire sheet of paper for one prescription. Eventually we got our vendor to support printing out multiple prescriptions on one sheet of paper. That helped, but many patients only need one prescription so that’s a lot of wasted paper. Beyond the green movement, wasted paper = wasted money.

With this background, that’s why I was intrigued by the DYMO Prescription Printer that I saw at MGMA. I’d worked with DYMO label printers before since the lab I worked with printed off lab labels directly from our EMR software. It makes sense that they could use a little bit larger printer and do the same thing with prescriptions.

It’s pretty obvious to see the paper saving benefits of using a DYMO printer like this, but I think the other advantage to this printer is its size. The printer has such a small footprint that you could easily put it a lot of places that a standard printer just won’t fit.

I admit that I haven’t done a full analysis of the savings using this printer compared with a standard printer. However, the nice thing about the DYMO printers is that they’re thermal printers which means that you’ll never have to spend money on ink or toner to print prescriptions. That’s pretty nice.

I’d love to have some of my readers try out the DYMO Prescription Printer to let me know what they think and whether they think I should add it to my list of EMR related technology products. Maybe I should see if DYMO will give one away to one of my readers to try out and report back.

I always love when small adjustments to current technology can make a huge difference. Or in other words, did I just write a post about a label printer? Sometimes the best innovations are subtle changes.

UPDATE: I just got word that DYMO will be happy to provide a product for review. So, drop me a line on my Contact Us page if you’re interested in trying it in your clinic.

Yesterday, I created a post on EMR & EHR called The Must Have EMR Feature – An iPad Interface. that post has driven quite a bit of discussion on Twitter and Google Plus. One comment from @2charlie hit me the most though:

2charlie – Charlie Gaddy
A decent web interface wouldn’t hurt either. RT @ehrandhit: The Must Have EMR Feature – An iPad Interface dlvr.it/tYkN7

Charlie’s twitter response highlights a number of interesting ideas. The first point that every SaaS EHR company will point out is that he said a web interface. We could go into the semantics of what is “the web”, but I have little doubt that Charlie meant a browser based interface when he said web. I’ll leave the rest of the discussion of “web” EMR interfaces for another post (plus, we’ve had that discussion many times on this site).

Instead, I want to focus on his use of the word “decent.” That adjective is interesting because no one would really argue that there aren’t plenty of web EMR interfaces out there. If you look at the EHR Scope EMR Comparison site, you’ll see a huge number of web based EMR companies listed. However, when you add the word “decent” to web EMR interface, I think we could have some really interesting discussion.

At least a couple times a week I get a doctor sending me an email or posting a comment on my website saying that “all of the EMR interfaces are terrible.” I don’t necessarily agree that “all” EMR interfaces are terrible, but a lot of them do fit the description quite well. I’m sure at this point all the EMR companies are thinking about their competitors and agreeing with me.

The iPad Opportunity for EMR Interfaces
As I thought on Charlie’s comment of a “decent web interface” as compared with an iPad EMR interface, I realized that the iPad provides a unique opportunity for EMR vendors with less than stellar web interfaces. While it would be great for EMR vendors to create stellar web interfaces or improve their current web interfaces, that’s much easier said than done. Many are working on older technologies. Others have so much company culture built into their interface that it’s hard to change. Many have large user bases that will freak out at the idea of a new web interface. Etc etc etc! The point being that the culture and history of many EMR interfaces make it hard to change.

In these cases, I see the iPad as a great opportunity to start fresh with your EMR interface. Many EHR vendors could use the iPad as a way to be able to create a new interface for their EMR with all the knowledge they’ve learned over the years baked in. Doctors expect the iPad interface to be different and unique.

I’ll be interested to see which EMR companies take this opportunity and make something of it. It’s the perfect chance for EMR companies to create a paradigm shift in their EMR software without having to admit publicly the mistakes they made in their first EMR interface. Unless you happen to be from an EHR company who built the perfect EMR interface from the start. Then, this need not apply.

Today at MGMA, Fujitsu together with Osmosyz announced a new scanner that supports the relatively new CDA “Unstructured Document” HL7 standard at MGMA 2011. I must admit that the press release is a little intense. However, I find what they’re doing with a hardware product to support HIE is quite interesting.

I don’t want the title of this post to be misleading. While certainly HIE has generally become synonymous with some large health information exchange entity, in this case I’m describing a hardware device (a smart scanner if you will) that acts as a small health information exchange. Basically, it’s more along the lines of Direct Project as opposed to NHIN. Although, I imagine that it could send the documents to some larger health information exchange if someone wanted to do so.

The larger application I see of this technology is as a replacement for the fax machine. In some ways, it’s like a second generation fax machine. The major differentiation I see between a document sent using the CDA “Unstructured Document” HL7 standard and a fax is all the meta data that comes with the CDA document.

The fax or scanning workflow for most EHR software consists of receiving faxed documents or scanning documents into what amounts to basically a bucket of all the scanned documents. Then, it’s up to the user to go in and sort through all the various faxes that have been received or documents that have been scanned. At this point, the user can assign the document to a patient in the EHR. You can imagine the challenges that this can pose. I wonder how many documents scanned or faxed into an EHR have been assigned to the wrong patient accidentally.

That’s what makes this new Fujitsu scanner quite interesting. If it’s receiving the document from an outside source, it will come with the meta information for the document as part of the CDA standard. That can then be leveraged to more quickly assign that document to the patient. Not to mention, then all of that CDA information is available for other uses within the EHR.

For inside documents that are scanned in through the Fujitsu device you can actually assign the document to a patient on the scanner itself. That’s right, you can identify which patient a scanned document belongs to while you’re holding the document in your hand. A much better way to ensure that the document you scanned gets attached to the right patient in your EHR.

I’m just touching on a few of the features of what’s possible with this new Smart Scanner from Fujitsu and smart documents. You can do other things on the scanner like dividing document scans between multiple patients.

Meaningful Use Monday Angle
Of course, as most of you know, on Monday we usually do our regular Meaningful Use Monday series. Turns out that the CDA Clinical Document standard that I discuss above is being adopted by ONC as part of meaningful use. I’ll be interested to see how this plays out over time, but don’t be surprised if EHR software has to support this standard in the future.

What I find more intriguing is that the above scanner could be used by someone who doesn’t have an EHR, but wants to exchange patient information. I still think that the long term solution to interoperability of patient information has got to come from connections with EHR software. However, this does illustrate that technology solutions can and will be created to exchange health information. In fact, some combination of these solutions could be a way to meet some of the meaningful use requirements around exchange of health information. You still can’t get the EHR stimulus money without an EHR, but technologies like this could help you achieve meaningful use.

I’ll keep an eye on how this technology progresses. I wonder how many EHR vendors will integrate with this type of technology. Whether we like it or not, documents are going to be a major part of healthcare for the foreseeable future. We’ll see if smart documents and smart scanners are an intermediate step to the health information exchange nirvana (whatever that might be).

Just the other day I was at a local Vegas Tech event and happened to run into a government contractor that worked in IT. As we got talking I told him about my work with EMR and EHR. Once he heard those terms he started to recount his experience evaluating a contract position where he was to work at connecting the VA system with another government entity. He then said, did you know that the VA software runs on something called MUMPS?

Of course I’ve heard all about MUMPS and so I told him how a huge portion of healthcare IT is run on the back of MUMPS (My understanding is that Epic uses MUMPS as well). Obviously, MUMPS has its benefits since it’s gotten us this far. I even remember some past threads where people have argued some of the advantages of MUMPS over newer database technology. However, I still stand in the camp that wonders how we’re going to get off MUMPS so we can enjoy the benefits of some newer, more innovative technology.

Something called the Axial Project basically asked this same question back in March 2011 when they posted about how to Architect Vista for 2011 (which is possible since Vista is open source). They provided a really insightful look into why MUMPS has done well in healthcare and what current technologies could replace it. Here’s that section:

So if I were starting a Healthcare IT company would I invest in building on Mumps/M? No. There might be some business in supporting legacy applications, but very little innovation. I am not attacking Mumps/M from a technical perspective, I am trying to be pragmatic as a business person. So we need find an alternative. So you probably think I am going to say MS SQL Server or Oracle thinking I want that 100/hr price tag. Thanks, but no thanks. So I am not in it for the money, I must go the other way. PostgreSQL or MySQL. Intriguing, but still a no go. I have learned over the past 18 months that Healthcare data has very little integrity. One of the reasons I believe Mumps/M has excelled. Storing objects vs Storing relationships in normalized structures is not valuable to this market. Too many views of the data are required depending on your role you play in the system. I would try to use a NoSQL database like MongoDB, Cassandra, or CouchDB. My preference would be MongoDB because there are drivers for Ruby, Java, .NET, and Python. Also, these systems are truly data entry/reporting tools at their core. I need strong query support which MongoDB has through it’s BSON data structures without a ton of map/reduce requirements. So let’s go back to finding some resources that can help.

The part that struck me was when it said, “I have learned over the past 18 months that Healthcare data has very little integrity.” That makes a lot of sense and explains why a NoSQL solution could work well.

Turns out, Axial Exchange has brought on the previous COO of RedHat, Joanne Rohde, to work on the project. Check out Axial Exchange’s presentation at Mogenthaler’s DC to VC 2011:

Looks like Axial has shifted from redesigning Vista, but they’re working on some interesting stuff.

What do you see as the future of MUMPS in healthcare?

Time again for my weekly round up of healthcare IT and EMR related tweets. Plus, a few thoughts from me about the various tweets.

@Craigley
Craig Bradley
I need a Watson robot in the room to be my knowledge/evidence coach & also EMR scribe while I listen/touch/care. @SeattleMamaDoc #chc11

The good news for Craig is that I’ve seen the people from IBM that did Watson working with the people from Nuance (most famous for Dragon Naturally Speaking) working on this. I don’t think it’s that far away.

@nickgenes
borborygmi
First real recommendation: have good backup plan when #EMR goes down; one makpractice case was lost by inadequate downtime system #SA11

This was pretty interesting. I’d love to learn more details about this malpractice case. No doubt you have to work on a proper system to handle EMR down time. I’ve written before about all the ways you could have EMR down time and the cost of EHR down time. It’s not a question of IF you will have EHR down time, but WHEN.

@JBikman
Jeremy Bikman
I’m very excited to see what Orion can become w/ Amalga HIS. My hope is that they emerge as a legit EHR/EPR/HIE player globally. Very cool.

This is interesting news since Orion is focused on the Asia Pacific market. Coincidentally, I’m just finalizing the details of me attending a Healthcare Informatics Conference in Thailand in March 2012. I’m interested to learn a lot more about Asia. You can read more about the Orion Health Deal for Amalga here.

@EMRDailyNews
EMR Daily News
Over 60 EMR / #EHR Apps Now Available in the iTunes App Store su.pr/1tfhMG

64 iPhone EHR apps on the app store. In February there were only 5 EMR apps in the Android marketplace. I’m sure there are a whole lot more now. Plus, the number of apps in the app store is a bit flawed since it’s not like people purchase their EHR software on the app store. However, it’s interesting to see how many are putting it there.