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.

I recently was asked by Deanna from Mighty Oak to check out a demo of their Chart Talk EHR software (previously called DC talk). It’s always a challenge for me since there are only so many hours in a day to be demoing the more than 300 EHR companies out there. So, instead of doing a full demo, I asked Deanna to highlight a feature of Chart Talk that set them apart from other EHR software companies.

She told me that Chart Talk’s killer feature was its integration with Dragon Naturally Speaking’s voice recognition software. I was very familiar with DNS and other voice recognition software, so I was interested to see if they really could create a deep integration of Dragon Medical over the other EHR software I’d seen that integrated it as well.

I have to admit that I was pretty impressed by the demo. It was really quite amazing the number of things that you could do with your voice in the Chart Talk EHR software. Certainly standard transcription like documentation worked out well in Chart Talk. However, the impressive part was how you could navigate the EHR with your voice. Here’s a demo video that does a decent job illustrating it:

What made the documentation even more interesting (and is partially shown in the above video) is the use of various DNS macros and the even more powerful built in macros for pulling in vital signs, past history, etc. Plus, I like the idea that when you have any issues with Dragon Medical, you don’t get someone at your EHR company who doesn’t really know much about Dragon. Since Chart Talk’s completely focused on Dragon integration, you know they know how to support it properly.

I of course only saw a partial demo of the Chart Talk software. So, I’m only commenting on the Dragon Medical integration in this post. It would take a much longer and more in depth evaluation to know about the other features and challenges to the software.

Plus, there’s no doubt that voice recognition isn’t for everyone. They tell me that some people do the charting with their voice right in front of the patient. That feels awkward to me, but I guess it works for some people. Then, there’s the people who don’t want to go through the learning curve of voice recognition. However, I’d guess that Chart Talk could make a case for being some of the best at teaching people to overcome that learning curve since every one of their users uses it.

I also know that Chart Talk originally started as DC talk. So, anyone considering Chart Talk should likely take a good look at how well the software fits with their specialty. I know the people at Mighty Oak have been making a big effort to work for any specialty. However, like every EHR software out there, they just work better for some specialties better than others.

It’s also worth noting that Chart Talk is a client server EHR. I guess the web browser isn’t quite ready for the processing power that’s required to have a nice voice enabled user experience.

Needless to say I was impressed by the voice recognition integration and how pretty much every command can be performed using your voice. I’d be interested to know of other EHR companies that are striving for that type of deep integration. I’m not just talking about being able to basically dictate into a text field. I’m talking about actual navigating the EMR with your voice.

I’ve come across a number of websites and people who’ve made the assertion that with the short time frames for meaningful use, a SaaS EHR is the only option to be able to meet the meaningful use requirements in a timely manner. Let’s see if I can do my part to clarify this idea which isn’t completely accurate.

First, there is still plenty of time for a clinic to implement an EMR of any type and get EMR stimulus money. At some point this might change, but at this point we are still far enough out that time is not an issue. Although, I’ll admit that it would be helpful if CMS and HHS would finally get some EHR software certified and provide some practical meaningful use details. Of course, these details shouldn’t be stopping doctors from evaluating and planning for their EMR implementation.

Second, it is worth acknowledging that in general a clinical practice can implement an EMR faster if it’s a SaaS EMR and not a client server EMR. The time for the server to be shipped to your office alone just takes time not to mention getting an IT person or your EMR vendor to install the server in your office. However, if you need more computers and a laptop to be able to use your SaaS EMR, you’re going to be waiting for computers to arrive anyway. Generally though, SaaS EMR is faster to implement than client server.

Of course, this doesn’t mean that you can’t quickly implement a client server based EMR. For example, I implemented a local doctors office in a week from when the server arrived. It was an incredibly fast implementation. Other than ordering time (which they had to order workstations also), it was as fast as any SaaS EMR implementation. So, it’s certainly possible. You just better make sure you have the right IT people supporting your implementation.

My point in this post is that it’s mistaken to say that SaaS EMR is the only option that’s fast enough to implement in time for meaningful use. Many of the client server EMR companies out there have really streamlined the process for installing a server in a clinic. Although, this is not true for all of them. So, it’s a question worthy of asking any EMR company if you’re looking at compacted time lines.

At least for now, it’s a mistake to rule out a great client server EMR just based on the meaningful use time line. We’ll leave the other arguments for ruling out a client server EMR in favor of a SaaS EMR for another post.

I thought it would be interesting to see which type of EMR setup readers of EMR and HIPAA preferred. If you’re not sure what I mean by the various options, I put a short description of each EMR setup below. Also, feel free to leave a comment about why you made the choice you did.

Hosted Web Based EMR (SaaS/ASP) – This is where the EMR company (or some outside entity) hosts the EMR and provides you access to the EMR usually through your web browser. Data is stored in their location and requires an internet connection to access the EMR.
Client Server EMR (Web Based) – This is where you host the server for your EMR in your office, but you can access your EMR server using a standard web browser. Data is stored on the server in your office, but access to the server using a standard web browser can be available anywhere.
Client Server EMR (Client Install) – This is the traditional model of EMR where you have a server in your office and you install a client which you use to access your EMR. Data is stored on the server in your office and is only accessible from outside the office using some sort of remote desktop connection.

Just sitting back and taking a look at the current EHR and EMR market, I have a strong feeling that we’re going to see a number of EHR vendors close up shop. Many of them may be disguised as purchases by bigger vendors who are trying to gain market share. Others will probably just close their doors completely and users of that EHR system will wonder why their support requests aren’t getting the response from their EHR vendor that they’re use to receiving.

I’ve talked previously about how EHR adoption will be slowed by the HITECH act. This slowing of EHR adoption is going to put a number of EHR vendors out of business. I have a feeling that far too many EHR vendors based their burn rate on their previous sales. Now that sales have slowed, they’re going to have to really fight to stay above water.

For those concerned, you might want to take a look back at my post on assessing your EHR vendor’s financial situation. Plus, I think it’s definitely worth taking a look at some contingency plans you have in case your EHR vendor does fail or get bought out.

The nice part of client-server based EHR systems is that you can usually keep using the EHR regardless of the financial viability of the EHR company itself. Granted, you’ll stop getting upgrades, but at least you can maintain the status quo. If you’re using an SAAS EHR, I’m not sure exactly what options you have available.

I should say that most EHR vendors won’t just shut their doors and leave. Most failing EHR companies will salvage what they can by selling to an EHR vendor that wants their customer base. However, when this happens, expect the new vendor to provide very light support for the purchased EHR software and a clear path to move to their software.

All of this said, I’m predicting a number of EHR companies to fail in the coming year.