This next list I found in my series of Top Health IT lists is going to be one that I think surprises quite a few people. It’s the list (PDF) of Top 10 Technology Hazards for 2012 by the ECRI. The Power Your Practice website did an interview with James P. Keller Jr. who works at the ECRI Institute about this list which is worth reading. Before the interview, they explain that the ECRI (Emergency Care Research Institute) was created in 1964 after a young boy in a Philadelphia ER passed away as a result of an improperly preserved defibrillator.

For this list, I’m not planning to go through each item, but I will list each item:
1. Alarm hazards
2. Exposure hazards from radiation therapy and CT
3. Medication administration errors using infusion pumps
4. Cross-contamination from flexible endoscopes
5. Inattention to change management for medical device connectivity
6. Enteral feeding misconnections
7. Surgical fires
8. Needlesticks and other sharps injuries
9. Anesthesia hazards due to incomplete pre-use inspection
10. Poor usability of home-use medical devices

The PDF document above goes into a lot more detail for each of these items including suggestions on ways to prevent these problems. I imagine many hospital safety organizations already know about these things and lists like this one.

Many are probably wondering why I’m bringing this list up on an EMR and HIPAA website. Besides the fact that the list is interesting on its own, I was also really intrigued that there’s nothing on the list that’s even remotely related to EMR & EHR software.

I’m sure if we sat down for just a little bit we could think of quite a few technology hazards related to EMR and EHR software. Not the least of which is EHR down time. I’m also reminded of this post I did earlier this year titled “EMR Perpetuates Misinformation.” Yet, EHR didn’t make the list…yet(?).

It will be interesting to watch this health technology hazards list over time to see if EHR software ever makes the list. I wonder how many hospital patient safety groups are worried about the safety of EHR software. I’ll have to get Katherine Rourke to dig into this over on Hospital EMR and EHR.

Be sure to read the rest of my Health IT Top 10 as they’re posted.

Next up in our evaluation of the various end of 2011 Health IT lists series is one that takes a bit of a look back at 2011. In this list, PwC lists what they consider the Top Health Industry Issues of 2011. The list starts with an interesting comment about the health IT spending in 2011:

More than $88.6 billion was spent by providers in 2010 on developing and implementing electronic health records (EHRs), health information exchanges (HIEs) and other initiatives. This surge is a sign of technology’s critical place in health system improvement.

$88.6 billion is a lot of health IT spending and larger than most numbers I’ve seen. Although, most numbers I’ve seen are only the EMR and EHR market and doesn’t include HIE spending and other healthcare IT initiatives. It’s quite clear that the health IT spending is up, and up Big!

Their list of top Health issues isn’t that surprising, except possibly one of them:

Meaningful Use – This has to be topic number one for health IT in 2011. It’s had a trans formative effect on healthcare IT and EMR and EHR as we know them. Pretty much every EHR vendor I’ve talked to basically had to take an entire software development life cycle to meet the meaningful use and certified EHR requirements. This is the dramatic effect of meaningful use on EHR development.

PwC actually focuses on how meaningful use will encourage patient participation in their healthcare or “shared medical decision-making.” To be honest, I’m not sure meaningful use has done much to help this goal, yet(?). Possibly meaningful use stage 2 and meaningful use stage 3 will help to further these goals. MU stage 1 has done little to encourage this. Regardless of the impact of meaningful use, shared medical decision-making is going forward fast and furious.

HIPAA 5010 and ICD-10 – The interesting issue for 5010 and ICD-10 is that they’ve basically been overwhelmed by meaningful use and EHR incentive money. Either of these changes alone would have been a reasonable challenge for a normal year. However, clinical organizations are battling through 5010, ICD-10 and meaningful use all at the same time. Are there any other IT projects going on that don’t involved these three things? I’d say probably very few.

Electronic medical device reporting (eMDR) – I found this point quite interesting. There’s been a lot of movement in 2011 in regards to what constitutes a medical device and who should take care of tracking and collecting the adverse events that occur on these devices. I don’t think we’ve come to a final conclusion on what will be considered a medical device and how we’re going to deal with reporting adverse events, but finally getting electronic reporting of adverse events is a good step in the right direction.

Be sure to read the rest of my Health IT Top 10 as they’re posted.

Editor’s Note: The following is a guest post by Jeremy Bikman. You can read more about the GE and Microsoft Venture on EMR and EHR.

Guest Post: Jeremy Bikman is Chairman at KATALUS Advisors, a strategic consulting firm focused on the healthcare vertical. We help vendors grow, guide hospitals into the future, and advise private equity groups on their investments. Our clients are found in North America, Europe, and Asia. www.KATALUSadvisors.com

Healthcare is being held hostage and it doesn’t even know it.

It is held hostage by burdensome regulations, by archaic practices, and (oddly enough) by technology itself. In this age of Facebook, Twitter, and LinkedIn, an age where anybody with internet access can connect to somebody else on the other side of the globe and share personal information and other data with the click of a mouse, it is impossible that you could visit a hospital in the next town over and they would be able to procure your personal health information as easily or as quickly.

Healthcare, globally and locally, is utterly huge and mind-blowingly complex, and thus absolutely needs the very best innovation of everybody involved. Yet, healthcare technology companies almost universally deliver products which are built on closed-minded concepts. They lock down their platforms, creating real barriers to interoperability, patient data exchange, and actual innovation. This is the present reality within, and across, practically every hospital on earth. The recently announced joint venture between GE and Microsoft offers hope of an alternate reality, one where hospitals can bring together data streams from all over the enterprise, while utilizing new innovations and technology as they see fit, including different best-of-breed sources.

Giving Hospitals a New Choice
There are huge flaws in how technology is delivered in healthcare today, flaws which impact quality of care within a hospital and across the entire industry irrespective of country or region. While the rest of the tech world is moving towards open platforms and collaborative delivery models, healthcare seems to be stuck in the dark ages of single-source solutions which compel all-or-nothing investments to the tune of millions and millions of dollars. Too often those investments fail. But, the more important question is why must hospitals be forced into all-or-nothing decisions in the first place? Why must they choose between integration and functionality, between a single platform, however mediocre, and a best-of-breed mix? We believe those are questions of the antiquated past and that brave new innovation can deliver a new avenue for hospitals who refuse to be painted into a corner. Hospitals shouldn’t have to choose between apples and oranges. They want, and should be able to get, both.

The Basics of the Joint Venture
Selected product lines from both companies’ health groups will be part of the new company. These products were chosen for their specific focus on “empowering connected patient-centric care.”

GE is contributing an interoperable clinical data model and decision support system via Qualibria. GE’s eHealth is an HIE solution in use at a large number of sites in North America. Microsoft is bringing Amalga to the table, which is a data aggregation platform which facilitates interoperability and a host of other advanced capabilities. Vergence and expreSSO come through Microsoft’s acquisition of Sentillion and provide strong context management and single sign-on solutions. The strategy appears to be one of leveraging Microsoft’s platform technology (Amalga) to underpin GE’s clinical depth (Qualibria, eHealth). Additionally, this model will allow hospitals and vendors to integrate best-of-breed 3rd party products into the ecosystem as they see fit. This mix of products and capabilities will enable a true best-of-breed environment emerge while still having the core elements of integration as well. This ecosystem will be powered by the partnership’s own applications and those built by ISVs. No other major vendor offers this unique model and set of abilities, although Allscripts is the one traditional EMR vendor that is building a strategy of accepting of 3rd party solutions.

Tackling the Big Problems

No one is saying that this joint venture is guaranteed to be a resounding success. However, we applaud the visionary model and risks this new team is taking. It looks like they want to address all the big hairy obstacles that every provider organization, region, and nation is facing. Big data? Absolutely. Enterprise analytics and business intelligence? Yes. Clinical decision support? For sure. Population management? You bet. Nobody else in the industry has shown they can tackle these issues even though every hospital is clamoring for this type of model. So why not this joint venture between GE and Microsoft? We say good luck, and more power to them.

The principals of KATALUS Advisors have worked with hundreds of healthcare organizations, vendors, and other consulting firms across the globe. The opinions expressed here are our own and are not intended to promote any specific vendor and do not reflect those of any other organization or individual.

The readers of EMR and HIPAA have been incredible lately in sending in great commentary on the EMR industry. The following is one such commentary about the issues associated with the now widely seen trend of Hospitals acquiring practices. The person asked to remain anonymous and for the names of the specific EHR vendors to be removed. I agreed since I think the trend is more important than the specific companies.

One trend that I find extremely (and personally) troublesome is the migration from homegrown EMR’s to less functional Hospital based EMR’s – a migration that is occurring frequently now that most small practices are being purchased by Hospitals.

In our case, our small hospital administration decided unilaterally (without MD input) to implement a poorly designed EMR from it’s IT vendor. This has been a colossal failure, as none of the doctors were able to use the EMR. Hospitals are easily seduced by their IT vendors, and think that they can have only one software vendor. They think that all EMR’s are basically the same, either a Ford or a Chevy mentality. They don’t want the docs interfering with the decision process. They don’t have any idea of information and work flow in a doctor’s office. And now they are getting ARRA stimulus funds, and sometimes grant money from local endowments.

We doctors have asked that administration find us one practice that is successfully using the EMR they selected. I think they found 1 doctor 1,300 miles away who was able to make it tolerable. The hospital EMR is CHIT certified, so that doesn’t mean much. Hospital Software vendors have quickly tacked together some sloppy EMR’s in order to save their customer base, and have easily deceived administrators into buying these inferior products.

Our administration has pulled back from implementation, just having us use the scheduler, nursing putting in vitals/meds, and we just enter the ICD-9′s and charges. But another push to MU is coming soon. I have told admin that they must cut my daily schedule from 20 to 10 patients per day. I think that the ARRA stimulus funds and this whole Medicare push for EMR is having a negative effect so far, as least for me. I was using [EMR Vendor] (and still am unilaterally) to organize my data, and generate notes. It’s light years ahead of the EMR the software vendor selected.

I have heard my story repeated many times. The trend of Hospital owned practices may be inevitable, but it has severe negative consequences for EMR, in my opinion.

John’s Comments: While I don’t necessarily agree with the broad ranging comments about administrators not caring or listening to doctors, I’ve heard it far too many times to disagree completely. There’s little doubt from my experience that many hospitals don’t do a great job listening to doctors in selecting an EMR software. However, I’ve also seen many doctors who are terrible to work with when it comes to any discussion of an EMR. So, let’s not kid ourselves into thinking that the doctors are completely blameless either.

One important point that is made is that doctors like using EMR software that they select. As more and more hospitals acquire practices, this issue is going to come to a head. I won’t be surprised if it’s actually a major part of the reason that the cycle of independent doctors starts again.

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?

As many of you know, when an EMR or EHR vendor wants to show me their system, instead of getting a full demo of their EMR I instead ask them to show me the unique features of their EMR. Basically, I’m interested in seeing the features, functions, approach, etc that makes an EMR or EHR vendor unique from the 300+ other EMR companies in the market today. This was my approach when EPOWERdoc approached me with a request to take a look at what they’ve created with their EMRDoc software.

Turns out that EPOWERdoc has been around for 12 years and is already in 250 hospitals in 40 states. That’s a pretty good footprint for an Emergency Department comnpany. In fact, I read that they’ve done 17 million Emergency Department visits in North America in their 12 year ED EHR history. Of course, these numbers come from EPOWERdoc and we know how good EMR install counts are from EMR vendors. However, even if that numbers bloated it’s a decent sized install base. Update from EPOWERdoc: The client numbers and ED visits are correct, we started out as a Paper Template system from software printing and that is where the large client base is predominantly. We are 36 months into the EDIS market with the product you looked at and have 18 live and another 9 by first qtr 2012.

During the short demo, EPOWERdoc showed me 3 or 4 interesting things about their Drummond Group modularly certified EHR. However, the feature that hit me most was the EMRDoc prose generator. In fact, this demo was one of the reasons that I’ve started predicting an EMR documentation revolution against hard to read, bulky, clinical notes.

I wish EPOWERdoc had a video of their EMR notes prose generator to demo it. If they create a video, I’ll post it to my EMR, EHR and Healthcare IT videos website. Until then, here are before and after screenshots of the EPOWERdoc interface which shows the granular data entry and the note that was created (click on the image to see the full image).

And now the image of the outputted documentation:

We could certainly debate the finer points of the user interface for inputting the data. Plus, a screenshot doesn’t show some of the other elements they’ve created to be able to quickly handle the input of the granular data elements. What hit me was how much the second image read like a clinical note. To be honest, as I read it I felt like I was hearing someone dictating a clinical note. Are their subtle differences where dictation is better, definitely. However, they seem to have done a good job of taking the granular data and turning it into clinical prose. I’ll be interested to hear some doctors thoughts on the above to see if they agree or disagree.

There were a few other interesting EMRDoc features that stood out to me in my short EMR demo.
-As an ED EMR, you have a different workflow than an ambulatory practice. As such, you need the ability to manage multiple open records at the same time. What I think EMRDoc does really well is switching between patients, but then also tracking your last documentation location for that patient.
-Related to seeing multiple patients, EMRDoc documentation feedback tool provides the user (doctor, nurse, etc) with a real time feedback as to the status of the level of documentation for medical coding as well as what has been completed in the note. In the ED where you’re regularly pulled away to deal with a pressing problem, the feedback statuses are a great little feature.
-EMRDoc has a feature that forwards clinical information and data from the Nursing Record to the Physician Record and from various sections of the Physician Record to other sections. Pretty slick implementation that reduces having to document that same thing multiple times.
-One of the big questions for an ED EHR like EPOWERdoc is how they deal with the hospitals large HIS system. EPOWERdoc’s answer was a partnership with Iatric who uses technology allowing data insertion into non accepting systems such as Epic, Cerner, McKesson or Meditech. I’d seen Iatric (They had the amazing trick shot pool table guy at HIMSS), but it sound like I should get to know them a little more. Maybe I can get Katherine Rourke to cover them over on Hospital EMR and EHR as well.

As I said, I didn’t do a full scale top to bottom demo of the EMRDoc ED EHR system, but I thought these were some interesting features of their EHR that were worth sharing. I’d love to hear some first hand experiences from any EPOWERdoc users. Let’s hear what you think in the comments.

Time for my roundup of interesting topics seen throughout the interwebs and related to EHR and healthcare IT.

@Allscripts
Astounding growth in use of EHRs – 5x in 2.5 yrs – Dr. Mostashari at #ACE2011 (via Skype) – does your doc use an EHR?

I’d like to see where Dr. Mostashari got those numbers. I think there’s little doubt that EHR use is up. If we say that 2.5 years ago it was at about 15%, then that would mean that using his growth number we’re now at 75%. That seems way too high for me.

@shelleypetersen – Michelle Petersen
US are starting to standardise vendor requirements for #healthit and language used in #EHR regions, important move

Is this a misread of what’s being done with meaningful use and EHR certification? I haven’t seen standards really emerge for most of this. I guess it does say “starting.”

Hospital EMR User Tracking Bill
Don’t ask me why, but this post about a CA Bill Requiring Hospital EMR Software to Track Users came across my tweet stream as well even though it was posted back in June. I guess that’s one thing I love about Twitter. It can bring back interesting content that you wouldn’t have seen otherwise.

After reading the post, I wondered if the CA bill passed or not. I’m guessing not. Although, I’m still shocked by the article’s comments that even an expensive Epic install at Kaiser can’t meet the requirements of reporting on what data for a patient in an EHR has been deleted and who’s accessed that patient data.

MGMA Conference in Las Vegas
I’ll admit that I’ve wanted to go to the MGMA conference for a couple years now. This year I’m lucky that it’s hosted in the beautiful Las Vegas. So, I’ll definitely be there enjoying the event. I’ve been thinking about doing a New Media Meetup at MGMA like I do at HIMSS. Are any readers interested if I put it together? If there’s only a few of you, we could just do a dinner or something. Let me know in the comments or on my contact us page.

As many of you probably know, I started a new Hospital EMR and EHR website that follows a similar pattern to EMR and HIPAA & EMR and EHR, but focused on the technology used in a hospital with the EHR being at the center (most of the times). The site has been growing like crazy with the wonderful Katherine Rourke posting most of the content.

However, one thing I found really interesting was that I took this post about Epic Possibly Being Victim of its Own EMR Success and posted it on Google Plus (UPDATE: You’ll need to add me to your Google Circle so I can add you to my EMR circle to see it. I forgot I only shared it with my EMR google circle and I can’t see how to make it public). I’ve just been dabbling around in Google Plus, and so I was surprised by the results.

In the post itself, there have been 6 comments about Epic EMR’s success. That’s really not a bad number of comments for such a new Hospital EMR blog.

However, the astounding part is that my thread on Google Plus that links to the post has already had 40 comments on it with some amazing insight from those commenting.

It’s still really early in the life of Google Plus. Maybe it’s early and the novelty of Google Plus is what’s currently providing the great discussion. I’ll have to seriously consider how I can incorporate that discussion into future blog posts.

LinuxMedNews just posted the announcement that OpenEMR is now a certified EHR. Here’s the quote from their announcement:

It’s official! OpenEMR has passed all ONC certification tests as a fully qualified emr that can be used to attest for incentive moneys. The official posting: http://onc-chpl.force.com/ehrcert/EHRProductDetail?id=a0X30000003mNwTEAU&retURL= appeared on the website 2011/08/19. Congratulations to all involved! OpenEMR 4.1 should be ready for download in a few weeks.

This is a really big announcement for the open source ambulatory EHR community. A number of other open source EHR are certified, but they’re mostly for the hospital EHR space. So, it’s a great thing for OpenEMR to provide an open source EHR to the ambulatory space.

Plus, I have to admit that it’s pretty great that an open source community can pull together the funds to actually be certified. The programming and development time is one thing, but getting the $20-30k to be certified is a big deal that I’m sure took a lot of effort. I actually wish I knew more about the process they used to achieve the EHR certification.

Now, OpenEMR users better start digging into resources like Meaningful Use Mondays. EHR Certification is the first step, but showing meaningful use of that certified EHR is the next one.

Big thanks to an avid follower of OpenEMR – Jojo the HITMAN who informed me of the news.

I’ve just turned in a story for InformationWeek Healthcare about the new “Essentials of the U.S. Hospital IT Market, 6th Edition” report from HIMSS Analytics. That report details the progress hospitals and integrated delivery networks have made in IT over the past year and gives an update on how far along providers are according to the HIMSS Analytics EMR Adoption Model. That’s the seven-level scale (eight if you count Stage Zero) that measures adoption of various EMR components.

At the top of the scale, 1 percent of nonfederal hospitals in the U.S. attained Stage 7 in 2010, meaning that the EMR served as the legal medical record for all departments, was capable of exporting patient records as Continuity of Care Documents and had data warehousing and mining in place. That was up from 0.7 percent in 2009. The number of Stage 6 hospitals—with electronic clinician documentation, full clinical decision support and full PACS for radiology—doubled in the same time frame, from 1.8 percent in 2009 to 3.2 percent in 2010.

Here’s how the entire scale breaks down:

Actually, the EMRAM Web page shows newer numbers, through the 2011 second quarter. We’re up to 1.1 percent for Stage 7, 4 percent for Stage 6, 6.1 percent for Stage 5 and 12.3 percent for Stage 4. HIMSS considers Stage 4 to be the closest to the current requirements for “meaningful use” of EMRs.

It’s nice to see progress in installing technology and it’s nice to see hospitals using EMRs in a “meaningful” way, but that doesn’t mean there won’t be problems. As everyone in health IT knows, EMR certification, a prerequisite for meaningful use, does not measure usability, and this still is the first of three stages for meaningful use. That means we’re a long way from perfect, or even ideal. How do I know this?

The mother of a good friend of mine is now on dialysis and eventually will need a kidney transplant because she was given a medication that is contraindicated for Type 2 diabetes, which she suffers from. The harmful interaction resulted in her losing about 80 percent of normal kidney function. This happened at a HIMSS Analytics EMRAM Stage 7 hospital. Apparently, either the patient record didn’t show she was diabetic, the medication order didn’t get flagged, or the ordering physician, pharmacy and administering nurse all missed or ignored an alert. As the chart above illustrates, the medication loop should have been closed by Stage 5.

I’m not going to name the hospital or give any more details because there’s a good chance a malpractice suit is coming. I’m also aware of a medical informaticist with a long history of implementing and working with EMRs losing his mother due to a medical error that an EMR exacerbated. Again, I’ve been asked not to say more because of the legal ramifications.

It’s no secret that healthcare is in trouble. In this push to install technology and earn Medicare and Medicaid bonuses for meaningful use, we can’t take our eyes off the ultimate goal, creating a safer health system.