One of the unforeseen and planned for challenges of having an EMR is the fact that software wants to be updated regularly. This is especially true for EMR software in its current state. EMR vendors are constantly making changes to the EMR software and for good reason. EMR software is rather immature as far as the features, usability, etc that it needs. Of course, an update to your EMR software is a great thing if it gives you even a half dozen new features that will make your life easier, your clinic more efficient and make your EMR more usable.
One of the challenges of updating your EMR software is managing the list of changes (most people call them updates since change is bad) that were made to your EMR software. The goal of course is to be able to update your EMR software and still keep on running your clinic as efficiently as possible. You want to know of changes to the software beforehand so that you’re not blindsided by a change that will cripple your workflow. You also want to make sure that you’re utilizing the new features that were added to the EMR in the best possible way.
I’d love to hear people’s experience with software updates to their EMR. How does your EMR company notify you of updates? How does your EMR vendor inform you of the changes that were made? How often do you update? Do you test the update before you actually do the update? How do you notify your end users of the changes in the next EMR software update?
Of course, the other wrinkle in this is whether you have a client server EMR or a SaaS EMR. In a true SaaS EMR, the updates just happen. In fact, they often happen whether you like it or not. So, I’d love to hear from some SaaS EMR vendors talk about what they do to communicate the updates to their EMR.
After I hear some comments, I’ll summarize the comments in another post and share my experience doing updates to an EMR software. I’m doing the same with my ePrescribing Challenges post and you’ll see that summary post about ePrescribing coming soon.
I’ve been reviewing EMR software for the last month and it astounds me how many vendors call their co-located or hosted solutions “ASP” or even “SaaS”.
When you access the exact same client server application via Remote Desktop but then tell the user that to have access to local hardware like scanners, fax-servers and cameras you have to install the client locally and tunnel it back to the ASP then YOU ARE NOT providing SaaS! You are simply hosting the application and leasing it back to the customer.
So if anyone is going to reply to this post from the vendor side, please clarify how you provide access to the application and weather or not the core is shared (multi-tenant). Otherwise your reply will be a waste of time and effort on all our parts.
to: # sillejo commented on October 7th, 2009:
Agreed that this “new, new thing” often generally called “cloud computing” is possibly over-hyped and obfuscated.
I hope you don’t mind if I chime-in on this from time to time and I hope you find my comments helpful.
What it means, what it can and can’t do, how the paradigm feeds back on a vendor’s biz model, the relative success of a cloud based EMR implementation, etc.
sillejo,
It’s somewhat about semantics. However, I’m with you on some sort of terminal server/Citrix access to hosted server not being a SaaS EMR or ASP EMR.
In the case of this post, you’re dead on that the updates to an EMR software on a “hosted server” based model is much more similar to an in house server EMR software update than it is to a true SaaS EMR. So, knowing that difference would be important.
Also, welcome to my site and I hope you’ll contribute in many future conversations.
Axeo,
I guess you and the Oracle CEO are on the same page as far as cloud computing. To me a lot of it is marketing hype. However, some of the technology behind cloud computing is so cool. Even if it’s a little too hyped.
There are several valid arguments and concerns here; the argument has been made that “cloud computing” is little more than reinventing the ASP and SAAS concepts. However, it involves some advances in technology that warrant some differentiation from earlier models.
The key technology enabler, in my opinion, is virtualization. Instead of allocating a server (or cluster of servers) to a single application, virtualization provides for better/fuller use of server resources by allowing multiple applications to share and by dynamically balanced across a group of servers. It also allows for new applications, or instances of an application, to be added quickly without the traditional delays in assessing, sizing, ordering, and building a new server. As an application requires more (or less) server resources, they can be provided via the virtualization management software literally “on the fly”.
Note that cloud computing can be implemented within an organization’s own data center. It isn’t limited to an external vendor model. If done correctly, it promises to reduce infrastructure costs, whether they are internal to an organization or external through a service provider.
So, if implemented correctly, cloud computing deserves a lot of hype. The issue is that many vendors will apply this term to the “same old services” previously provided. This results in disillusionment and the conclusion that it’s nothing but hype.
When you say “cloud computing” do you mean Web host server and network infrastructure / or Amazon, or Google AppEngine / or SalesForce.com model / or some of each.
Again, the issues at the highest level are expectations and the customer/vendor relationship as unknowledgeable buyer.
The accusation or at least insinuation is that some vendors are jumping on the cloud “bandwagon” knowing full-well that their product won’t pass various litmus tests and the value proposition and risks are not well understood by the buyer.
For example, when cloud vendors (whatever that means) are asked about possible Internet pipe outages, their response is often not a helpful answer or plan, but often a sharp retort like “yeah but the doctor’s office could burn down also”.
I mean really, where do we go from there? The credibility is shot. If vendors want to start-out adversarily, if they won’t be completely candid, we aren’t going to make progress toward the common goal.
Vendors, and VCs can compete but this HIT thing ain’t dot bomb or Social Networking x.0 stuff.
This is serious.
I always love to think back to the universal sign for the internet being a “cloud.” Under that definition, everything is cloud computing (more or less). Certainly there are a few hundred definitions of cloud computing out there and none that broad.
No doubt the challenge is for a doctor or practice manager, to look at the following terms: cloud computing, VMWare, Virtual machine, hosted, web based, SaaS, Google Apps, Amazon EC2, clustered server, ASP, etc etc etc and be able to know what their really getting and the challenges associated with each environment. Of course, this becomes even more difficult since 98% of them just want it to work. Otherwise, they don’t care.
There are number of guesses at the origin, and yeah, one is the classic picture of a PC/LAN diagram connected to the “Internet” with the Internet encircled by what looks like a cloud.
More intriguing is the response I get from the younger folks when I take them through the centralized computing time share IBM green screen model from 50 years ago.
History repeats?
“Vendors, and VCs can compete but this HIT thing ain’t dot bomb or Social Networking x.0 stuff.
This is serious.”
I think many people agree that this can be serious stuff for the practice but there are just as many offices that see this as a bane to their professional life. Herein exists the dichotomy. The main reason there are fly-by-night vendors is because the market keeps sustaining them. Many SMB medical facilities do not want to pay for IT infrastructure, they believe they can’t afford it, they believe it’s outrageously priced, they believe paper is better (for them) and the reality is that they will keep trying to do EMR/PM on the cheap. It’s the same reason you used to find used car lots on every other block in some towns. Not everyone will trust or go to those kinds of vendors, but enough will and it clutters the market as well as the landscape.
So, is this the dot-comlike era? Perhaps the government will serve as the venture capital catalyst. But really, there needs to be a greater discussion in the medical community about the importance of IT in general. Otherwise they will continue to buy products from whatever vendor has a slick salesguy with a good pitch “buy now and we can give you our end of the year discount!” “if you sign today, I think I can work another 25% off” “we keep our costs down by using magic carpets to get to work”
To Sillejo’s comment on Oct 9:
I believe the discussion in the medical community about the importance of IT in general doesn’t need to begin with the doctors and practice managers.
It is up to the Healthcare IT community to begin by more effectively aligning technology to the business needs. Instead of “delivering IT”, we need to change our perspective. Healthcare IT’s business should be delivering healthcare. Until we can speak in business terms and from a business perspective, we will continue to be viewed as the “used car lot sales people”.
We absolutely must prove “what’s in it for the business”. Instead of using technical buzzwords such as cloud computing and virtualization, we need to use language the business will more likely embrace.
Brad,
It is unsound to ask the IT community to find the solutions to problems that healthcare providers only vaguely understand themselves and then expecting those same providers to wait until you, the IT guy, finds the magic bullet. Today’s reality is that they can no longer wait due to the incredible push by government and insurance companies into electronic transactions. That pressure will not be released by an IT guy coming up with the right terms or verbiage to describe their product “in business terms”. That is the same marketing crap that every company pushes when their product is having trouble finding a market. “aligning with business needs” is code for “we convinced this guy that the ROI I told him is real”
If IT was serious about “being aligned to the business goals” then a talented proven company would sink a bunch of money into a partnership with several provider types and CREATE a set of basics that could then be adapted to a niche market need (podiatry vs dentistry vs general practitioner) But that would mean an IT company having a vision beyond 5 years and the only ones that could do that kind of thinking no longer exist in the same way (DEC, IBM, HP, Xerox) due to massive cuts in R&D and NPD over that last 30 years. So now it is left to the Venture capitalists to pick and choose which software maker might hit a homer in 5-10 years and in the meantime my doctor still TYPES his notes to me on an IBM typewriter, my optometrist can only “fax” me my prescription (who the heck owns a fax anymore under the age of 35?) my dentist can not let me book a cleaning on-line and as of a year ago I still can not get an electronic copy of my MRI taken of my shoulder so I have to find room in my office for the ginormous actual photos of my rotator cuff so when I go to a new PT, he can see the images without having to wait over a week to get them sent over by the hospital.
This has nothing to do with IT needing to align to business goals and has everything to do with practitioners being dragged kicking and screaming into the electronic age. Unless they decide to find serious solutions to these serious problems an IT vendor might as well take their NPD money and head to Vegas, the odds of winning are better and at least there they give you a drink before saying “better luck next time”.
I recently had consulted with a BA for a SMB office and they spent months gathering requirements, qualifying product, watching demos, interviewing references, evaluating technical viability (my end), running NPV of the deal and verifying credentials of EMR vendors. Right when they made a decision one of the principles came back and said “the look of this chart doesn’t work for me and I don’t like the fact that they have to customize it to get it right. Let’s go find someone else who already gets our industry and use them.”
That my man is the quintessential problem, in a nut shell.
My apologies for the rant, although I mean every word, it could have been more concise and less, well, Dennis Miller-ish (did I date myself enough there?)
But one thing I left out – If we are going to have market driven health care then the people getting paid the big money to make the big decisions need to take on the big responsibility of educating themselves. I’m sorry if Johns Hopkins or Harvard medical neglected to teach them business acumen but that does not abdicate you from the responsibility. If you feel that it’s just too much then hire a consultant, pay them to follow you around for 2-3 months and take notes, then let them find a solution for you. That’s more personal time than they likely give their accountant and yet they trust that person with 25-30% of their gross income each year.
I take a Saturday off and look what happens. Actually, I love the strong conversation about things. It’s nice to have people with passionate feeling sharing differing points of view. Thanks for sharing.
Axeo,
Yes, I’ve often thought that history was coming full circle with virtual machines. Kind of funny to see. However, the technology is so much better now.
sillejo,
It’s interesting that you think that people are buying cheap EMR software. Maybe I’m misunderstanding you and we are on the same page, but I think the problem has been that people have spent so much on overpriced EMR software that they’ve cut out other important things like IT infrastructure or extras the EMR vendor provides but cost more money. So, they’re paying a TON for the software, but cut out other important elements to an EMR implementation to “do it on the cheap.”
Now on to Brad and sillejo’s comments on whether practices need to take a bigger role or whether IT vendors (I assume this means EMR vendors) need to take a larger role in getting EMR software implemented.
Of course, the answer is simple: they both carry some of the blame.
There’s absolutely no doubt that many practice manager, doctors, healthcare professionals are kicking against an EMR implementation as hard as they can. The example given of the doctor saying he didn’t like the note style after the huge search process has been played out far too many times. If someone doesn’t want a certain EMR, you can always find a fault. There’s no such thing as the perfect EMR and people can easily make an excuse for any EMR not working. The reality is that until they decide the want it (or some strong leadership in the clinic decides this) we’re unlikely to see a huge change in EMR adoption.
Now the EMR vendors have as much blame as anybody for doctors and medical practices not implementing an EMR. Many of them (not all, but far too many) cared more about the sale of product than they did the successful implementation of their product. They’ve also sold unusable products or underdeveloped products. All of these have scarred the industry and provided good reasons for doctors and medical practices to have been afraid of implementing an EMR.
Point being that far too many EMR vendors focused on the sale of the product and not the successful implementation.
An EMR fundamentally changes multiple processes in a clinic. If that change isn’t managed properly even the best software can fail. It’s not like a word processing program where everyone sees it once and says, I know how to use that. Maybe they should be. If they were, we wouldn’t have nearly as many problems.
So, I personally think there’s plenty of blame to go around. The light at the end of the tunnel for me is that I think there are a lot of good EMR software out there. There’s also a lot of information about the change that’s required in an EMR implementation. People know more about what to expect when they implement now than they did before and just the changing of expectation level is huge.
Now we’ll just see how many people can find usable EMR software and then spread their successful implementation to other people.
Great discussion. Maybe I should make it it’s own blog post for all to see, enjoy and join in.
“They’ve also sold unusable products or underdeveloped products.”
My interpretation of “cheap” revolves around the quality of the products, not necessarily the price. But on price, many practitioners can see the same quality in overpriced software that they see in fly-by-night companies leading them to believe they should be able to get the same product for less, and in that sense they are not wrong. The nuance that is missing for the practitioner is the IT detail that separates cheaply made products from higher quality products plus the support methods and requirements from the vendor. Good support requires good support products and infrastructure. If support means the vendor uses VPN or RD to get into your server but there is no record of what was done, how it was resolved and no method for the practice to view the support cases, then what effort have you as a vendor put into your support? None. If you as the vendor still rely on Windows 2k3 server, don’t support anything other than Windows XP, don’t have a migration path for the customer when you move to a new server platform (I have to remind every single vendor that Win 2k3 is already 7 years old, then I ask them to tell me what I do when the next upgrade of theirs does not go on this server platform…none of them have an answer) then what are you really doing in your development department? Do you even have one or are you hacking away with new guys on old code in the back of a warehouse somewhere in Bangalore? Not that you can write good code in India, because I think you can, but you need strong code path leadership from the development team and that is lacking in the off-shoring places like India.
just wanted to give more meat to my “cheap” comment
I completely agee with sillejo’s comment: “It is unsound to ask the IT community to find the solutions to problems that healthcare providers only vaguely understand themselves and then expecting those same providers to wait until you, the IT guy, finds the magic bullet.”
The position I’m trying to make is that it is even more unsound to expect any success if the IT community pushes its solutions without first understanding, at least to the same “vague” level as the providers, what the problems and realistic opportunities are.
I recently attended a healthcare conference where I set out specifically to find exhibitors who provide IT consulting services. Out of 20 vendors I conversed with, all but one had a consulting service whose primary purpose (my opinion) was to sell their product.
As an IT leader, my greatest source of frustration is when a “consultant” sells their service for the purpose of understanding the business vision, strategy, objectives, and challenges – only to learn in the end that they are pushing their “cookie-cutter” approach for selling a product or line of services and then trying to convince the business to re-engineer its core practices and processes.
The good news is, I did find one vendor at this conference who seems to get it right. We need more of these.
Herein lies the pain that the healthcare industry has been experiencing. But I also see an opportunity for HIT to realize – if it takes a longer term business view rather than the shorter time IT pusher view.
I also attended a recent business technical luncheon where the CIO for Texas Instruments and the CIO for Texas Health Resources provided the program. They each provided great arguments for how IT can succeed based on their experiences and observations. And success begins by IT understanding that their end-purpose/deliverables aren’t IT hardware/software solutions. Instead, IT must focus on how to successfully and efficiently deliver the products or services of the business they support. Then, IT will be seen as a “partner” and “enabler” by practitioners.
John, sillejo, Brad,
At a high, simple level I see it as follows …
The key industry in the US is collecting unstructured data in various forms (paper, film, etc,).
All of a sudden the US Gov decides that data would be useful to them and useful to exchange and share within the industry in a “structured form” — computerized, digitized and queriable — ie to some set of standards.
Unstructured to structured, and collect it damn near real-time, with everyone on board in the next year or so is one heck of a bridge to cross.
Brad,
You wrote, “I recently attended a healthcare conference where I set out specifically to find exhibitors who provide IT consulting services. Out of 20 vendors I conversed with, all but one had a consulting service whose primary purpose (my opinion) was to sell their product.”
This comment reminded me of an article I wrote about the various types of “EHR consultants” that exist in the industry. I call them EHR salesman dressed in EHR consultant clothing. Far too many of them out there and that number is growing thanks to the EMR stimulus money.