EHR Adoption | EMR and HIPAA

The EMR Language

If you haven’t read this insightfully candid post by Rob Lamberts, MD, you should go check it out now. Here’s the opening which should get you intrigued:

OK, I’ll admit it: I had no idea. I thought that the whining and griping by other doctors about EMR was just petulance by a group of people who like to be in charge and who resist change. I thought that they were struggling because of their lack of insight into the real benefits of digital records, instead focusing on their insignificant immediate needs. I thought they were a bunch of dopes.

Yep. I am a jerk.

My transition to a new practice gave me the opportunity to dump my old EMR (with all the deficiencies I’ve come to hate) and get a new, more current system.* I figured that someone like me would be able to learn and master a new EMR with ease. After all, I do understand about data schema, structured and unstructured data, I know about MEDCIN, SNOMED, and HL-7 interfaces. Gosh darn it, I am a card-carrying member of the EMR elite! A new product should be a piece of cake! I’ll put my credentials at the bottom of this post, in case you are interested.**

So, imagine my shock when I was confused and befuddled as I attempted to learn this new product. How could someone who could claim a bunch of product enhancements as my personal suggestions have any problem with a different system? The insight into the answer to this sheds light onto one of the basic problems with EMR systems.

Since he said it, I had to take a look at his “credentials” to provide some perspective on the post as well:

I did my residency at Indiana University, the land where Clem McDonald, one of the pioneers of electronic records made our records electronic when personal computers were still new (I attended from 1990 to 1994). It was there I became a believer in computerized records.

In practice, I installed MedicaLogic’s EMR in 1996, as one of the first users of their Windows based product, Logician.

Within 2 years I was on the user group board, and was elected president in 1998. I was a regular speaker at the conferences and known for my profuse production of clinical content (called “Encounter Forms”)

In 2003, I applied for and won the HIMSS Davies Award for ambulatory care for our practice, recognizing our achievements with EMR in an ambulatory setting.

After that, I served on several committees for HIMSS, gave talks for multiple other groups (NHQA, National Governors Association), giving the keynote talks for the HIMSS series given around the country to convince docs to adopt EMR.

In 2011, I participated in a CDC Public Health Grand Rounds as a speaker from the physician perspective on the subject of Electronic Medical Records and “Meaningful Use.”

Finally, he ends with the money quote, “So to those I have scorned in the past, I bow my head in shame. I got good at using a complex tool that allowed me to manage the insanity of our system. It turns out that my skill was a very narrow one.”

There are so many fascinating things about this post. Many of which we’ve discussed many times before here at EMR and HIPAA. The first one that I want to highlight is the idea that EMRs were developed around our insane payment system as opposed to around amazing patient care. Long time readers might remember my starry eyed dreaming about what an EMR would look like if it didn’t have to worry about billing. Sadly this isn’t the state of EMR software and likely won’t be in the near future. However, it is the biggest challenge that an EMR vendor faces.

Dr. Lamberts is right that there are good and bad parts of every EMR system. No EMR system is perfect. Instead, each one does certain things really well and certain things subpar. This is a feature of pretty much every software. When an EMR system doesn’t do something well it could be because they just haven’t had time to optimize it. Although, more often, their are subtle development issues which make changing an EMR workflow very difficult. Not to mention the impact of a subtle workflow change to your existing EHR users.

Thinking back to Dr. Lamberts post, he talks about how he’d become an expert on the intricacies of his EMR software. If his EMR vendor were to change that workflow to a more optimized one, he would have revolted. Maybe the new workflow is better, but the fact that he knew the old workflow has value as well and changing it has its own costs. Thus the challenge to updating any EMR software.

No EMR is perfect. Choose the EMR whose challenges you don’t mind dealing with on a daily basis.

Another message I get from Dr. Lamberts post is not to give too much value to awards, groups, and industry committees. Not that I really did before anyway. I’ve always been a take it with a grain of salt kind of guy.

What Can We Do Today That We Couldn’t Do Five Years Ago in Health IT?

Written by: John Lynn

As I’ve been seeing the flood of creativity and innovation that can be seen at the CES (Consumer Electronics Show) in Las Vegas, I’ve often been witness to the amazing things that are possible today that wouldn’t have been possible five years ago.

There are so many examples of this happening throughout the IT world. A simple example is how many things are now possible with a mobile device that has always on mobile internet access (3G and 4G), an accelerometer, GPS, video camera, and voice recognition. 5 years ago we had little pieces of each, but now we have all of those items easily packed into one device. Think of the innovation that is happening that would have never happened if we didn’t have those technologies available.

I started thinking about how this applies to healthcare. What things can we do now that we couldn’t do five years ago?

Some of the technologies above are perfect examples of technology we have now that wasn’t available five years ago. A company like AirStrip Technologies wouldn’t even exist without the technologies mentioned above. Yet, because of those technologies, they’re now taking healthcare data mobile.

Five years ago we were at a pitiful EHR adoption level (10-20% depending on who you talked to). Now we’re at a much higher EHR adoption level. What is healthcare doing to capitalize on this increased adoption of EHR? What amazing things can we do now with EHRs in place that we couldn’t even consider before?

One example might be patient portals to access your clinical information. Before an EHR, the patient portal didn’t make sense because it didn’t have the EHR data to back up the portal. Once you have an EHR, it’s much easier to put up a portal that’s integrated with a patient’s record. That’s a simple example, but hopefully we’re going to see a lot more dramatic options. If we don’t then something’s wrong.

I guess the key message is that incremental progress in multiple areas combined together can lead to extraordinary breakthroughs. We need more of those in healthcare.

The False Economies of EMR

Written by: John Lynn

In my recent look around the EMR twittersphere on EMR & EHR, I briefly commented on the challenges of choosing the wrong EMR and EMR Switching. Dan Haley from athenaHealth asked for some deeper clarification of my comment, “I’d say the biggest driver of EMR switching is thanks to the EHR incentive money and meaningful use.”

Here was my response:

I think there are a whole list of things in the HITECH act which encourage and promote the use of outdated technologies. I’m sure this is something you agree with and know all about as well.

My core argument has been, sure we’re seeing an increase in EHR adoption. However, what if the EHR incentive money is incentivizing doctors to adopt the wrong EHR. By wrong EHR I mean one that they don’t like, that can’t adapt to changing technology, that can’t support the future Smart EMR requirements that are bound to come, that kill a physician’s workflow, that cause a doctor to not want to be a doctor, etc.

I think we may be headed this direction and the number of doctors switching EHR software is a decent example of why this is the case. I’m sure that some would argue that meaningful use is driving people to switch EHR software and that the switch we’re seeing happening is from EHR software that isn’t highly functional to EHR software that is highly functional.

While this argument is true in some cases, there are just as many cases which illustrate that the EHR switching was because their first MU EHR was such a terrible experience that they had to switch EHR. Plus, we’re just at the start of this. Many are painfully grinding through the day to day with an EHR they hate. Wait until that explodes.

Even worse is those clinics that are switching EHR for the sake of EHR incentive money and go from an EHR they enjoy to one they hate. Add in the many doctors who are stuck using an EHR that was selected by some large company who didn’t worry too much about the physician needs and we’re in for a crazy next couple years.

Hopefully this gives you a better idea where my comment was coming from. Needless to say, I’m not sure that HITECH has been a benefit to doctors. The short term numbers might look good, but it might have just created some painful underlying difficulties going forward.

With all of this said, there are some beautiful EHRs out there that make doctors lives better. I’m pro-EHR when it’s done right. I just don’t see meaningful use and EHR incentive promoting the right EHR adoption methods.

This provided some interesting background for a conversation I had recently with a doctor. He told me, “It seems like there are a number of false economies driving EMR adoption.”

I think meaningful use and EHR incentive money driving EHR adoption is a false economy. This doctor described to me how many of his colleagues weren’t using the EHR that they wanted, but instead were using an EHR that they “had” to use. What are some of the forced requirements for EHR that create these false economies besides meaningful use and EHR incentive money?

Another False EMR economy is around HIE connections. Many doctors can’t select the EHR they want to use and fits their workflows best because their local HIE may or may not choose to support a connection with that EHR. So, the doctor opts for an EHR that does connect with the local HIE even though it wasn’t their EHR choice.

Hospital Connections is another false economy. Similar to an HIE, many doctors will opt for what they consider to be a less than desirable EHR because it’s the one that works with their local hospitals.

I’m not trying to pretend that doctors should be the end all be all in EHR selection. A physician can think one EHR is the best and not realize until after using it that another EHR would have been better. Sometimes you think you have a great EHR until you actually use another one and realize what you’re missing. However, the easiest recipe for disaster with EHR is for a doctor to hate using an EHR. As I mention above, it will not end well and will drive the future EMR switching that I’ve predicted.

Meaningful Use the Commodity – Meaningful Use Monday

Written by: John Lynn

I decided to take a step back this week for Meaningful Use Monday to look at where we are in the new world of health IT which includes the commonplace terms of EHR incentive money and meaningful use. Plus, I’m probably waxing a bit nostalgic today as I think about the David Brailer keynote at the Digital Health Conference today (follow my tweets on @ehrandhit for more coverage) where he spoke a bit about the origins of healthcare IT.

At this point it seems that meaningful use has become basically a commodity. There are very few EHR vendors out there now that aren’t certified EHR that can help a physician get to meaningful use (Although there are some non-certified EHR still). Basically, if you are doing EHR, then more than likely you are doing meaningful use. Or at least you’ll have that opportunity if you want. Some would argue that means that this result is a function of the meaningful use bar being set too low.

In fact, that is largely what the congressmen’s argument was in their letter to HHS about halting meaningful use. The real question is whether this is a problem. I personally don’t mind all the EHR competition. I think it would have been worse if the government incentive, meaningful use, and the RECs essentially narrowed the field of EHR vendors down to only a few.

The argument on the other side is around the “paradox of choice.” There’s little doubt that many practices are in a situation where there are so many EHR choices that they make the decision not to choose. However, I see this more as an excuse not to do EHR from people who didn’t really want to do EHR in the first place. I’m not sure these people would have been doing EHR even if there were only a few choices.

This does leave us with a challenging problem going forward. The EHR churn rate is going to go through the roof. David Brailer pointed this out today in his keynote and he’s right that it’s already happening today. Although, the majority of the EHR churn that’s happening now is from those organizations that are going after meaningful use. The major EHR churn rate of the future is going to come from EHR consolidation.

What does this all mean? Now more than ever, an organization needs to do good due diligence on the stability of the EHR software. Notice that I didn’t say EHR vendor. Just because you’re a large EHR vendor that’s financially stable doesn’t mean that the EHR software is safe (see Exhibit A and Exhibit B).

One thing is clear though, meaningful use and EHR are here to stay. There’s no escaping EHR. We’re finally back to the point where doctors are no longer asking if they should do EHR. Instead, they’re asking how, when and which EHR they should do. This is a very good industry trend.

Lawsuits Will Eventually Drive EHR Adoption?

Written by: John Lynn

In the recent #HITsm chat, tireless patient advocate Sherry Reynolds offered this intriguing tweet:

Once EHR’s are the standard of care sadly lawsuits will drive adoption .. “so why didn’t you see the lab results doctor?” #HITsm

July 27, 2012 9:36 am via TweetDeck ReplyRetweetFavorite

@eHealthSherry

Sherry Reynolds

The first question I’d ask based on this tweet is when will EHR become the “standard of care.” I’m sure that some could argue that now based on the $36 billion in EHR incentive money that the government is spending. However, even the most optimistic EHR adoption numbers are at 50% and I’d put it closer to 30% with ambulatory EHR dragging that number down. With that said, what would it take to have EHR as the standard of care that a doctor provider? I’m not a lawyer, but I know a number of healthcare lawyers read this blog. I hope that some of them will chime in with their thoughts.

Sherry’s last comment about not having the lab results points more towards the exchange of healthcare data being the real issue a doctor could face. Not only would this be a potential lawsuit issue for doctors, but at some point enough patients will ask this question as well. I’m sure most doctors aren’t worried since we’re pretty far from that tipping point.

I do think that doctors are quite attune to liability and can be a very big motivating factor for them. I think the same will happen with insecure text messaging in healthcare. The first couple lawsuits against a doctor for sending PHI over text and we’ll see widespread adoption of secure text platforms.

While I can see some of the realities that Sherry tweeted about, a part of me really hates to think that fear of lawsuits would end up being the driving force behind EHR adoption.

Is Lack of EHR the Real HIE Problem?

Written by: John Lynn

HIE (Health Information Exchange) is a really interesting thing. It’s something we all know we want to have happen and so far millions and millions of dollars later no one has been able to crack the code on how to make an HIE a reality.

The benefits of having an HIE are real and apparent. I’ve never heard anyone argue about whether an HIE would bring benefits to healthcare. It’s simple to see that having all of your health information available to a doctor at the point of care is valuable and useful. We don’t need a study to show that. We know it’s the case. Having the information could be the difference between life or death.

We all know that if a doctor can get the lab or radiology information from the HIE, then they don’t have to order another duplicate lab or x-ray. They might still order another one (for a bunch of perverse and maybe some legitimate reasons), but in many cases they wouldn’t have to order one since they’d already have the info they need.

Why then isn’t HIE a reality today?

For the longest time I’ve argued that there are two main barriers to HIE: governance and funding. By governance I mean, “How are we going to make sure that the right people get the right information and that the wrong people don’t get the information they shouldn’t have?” Funding is really about finding a sustainable revenue model for an HIE.

While I still think that both of these issues are real challenges for HIE, I recently started to wonder if the real challenge for an HIE is that not enough doctors and hospitals are using EHR. We want HIE’s to be successful, but can an HIE be really successful for doctors and hospitals that don’t have an EHR?

The lack of EHR adoption might be the biggest impediment to HIE.

Top Healthcare IT Vendors by Revenue

Written by: John Lynn

For those of you who aren’t familiar with the now a year old Hospital EMR and EHR, you should check it out and subscribe to the email list. The site has been growing like gang busters and people are loving the content on that site. I’d wanted to do a hospital EHR focused website for a long time. Certainly there’s a lot of cross over between ambulatory EHR and hospital EHR, but there are also unique differences in the hospital EHR environment that were definitely worthy of their own discussion platform. Plus, we like to cover other aspects of hospital IT.

One of the recent series that Anne Zieger started on Hospital EMR and EHR is called the Top Hospital HIS Vendors by Revenue. She’s already covered the top 3: McKesson, Cerner, and Siemens. She’ll be going through the rest of the Top 10 Hospital HIS vendors by revenue over the next weeks.

It’s really fascinating and amazing to see the enormous revenue numbers that each of these companies produce. Even more amazing is that we’re really only at the beginning of EHR adoption. There is so much of the EHR market that still is out there waiting to implement an EMR solution.

Of course, the real question is which vendor is going to capture this market share and which company will eventually be created that will take the market share from the incumbents. I’m sure it’s hard for many to believe that some upstart company could take down these large companies, but it will happen. That’s the cycle that occurs over and over again. Although, I will make the prediction that we won’t see much jostling in the hospital EHR space during the HITECH EHR incentive money time frame. The opportunity to take market share will likely happen post EHR incentive money.

Resistance to Change Will Fuel EHR Adoption

Written by: John Lynn

Resistance to change is the number one reason doctors aren’t adopting EHR software. Sure, doctors will often give a lot of other reasons why they’re not adopting EHR software, but in most cases those are just shields for the real reason they don’t ant to adopt EHR software: Change.

Doctors are certainly not unique in this arena. None of us like to change. I’m a creature of habit as much as the rest of us. In fact, I just tweeted yesterday that I need to change my method for writing posts. I know it’s the right thing to do and would make me more productive and probably increase the quality of my posts, but I’m resistant to changing the approach that I’m comfortable doing. Doctors are no different and let’s be clear that documenting in an EHR is different than a paper chart. An EHR implementation requires change.

While resistance to change is the current barrier to EHR adoption, I would also assert that resistance to change is going to be the reason why EHR adoption will become the norm.

I’m sure this will make some of you feel a little uneasy. What we have to realize is that most new doctors coming into the medical profession love technology and can’t imagine having to go find a paper chart. They can type faster than they can write and so they idea of writing in a paper chart would be a big change for them. These doctors are use to only reading typed material. They don’t care to learn how to read physician hieroglyphics. These new doctors don’t see carrying around a device as a burden, but as a normal part of life. Taking that device away is a change for them. They won’t want to change their digital ways in order to live in a paper chart world.

In a story I’ve often related, I saw this first hand when my medical student friend told me he hated his current rotation because they used paper charts. He then went on to say, “I hate paper charts because I can type faster than I can write. And…” The glazed over eyes was when I could see that for him he couldn’t see any justification for using a paper chart. He wasn’t quite sure how to articulate why he didn’t like paper charts, but he just inherently knew that he didn’t.

Time is the great healer. With enough time, the resistance to change will be against those who want a doctor to use a paper chart.

Funny Video Related to the Move to EHR in Healthcare

Written by: John Lynn

In my post Paper Has Healthcare Spoiled, Joe Frank aptly pointed out this awesome video (embedded below) that provides a really funny take on when books were invented. I know I’ve posted the video before, but not only is it so funny that it’s worth another view, it’s also a perfect corollary to the previous post. In fact, I had this video partially in mind when I wrote the previous post.

For those who haven’t read the previous post, you should. If you have, then enjoy this wonderful video. Those working in healthcare IT will no doubt see some similarities.

Predicting a 6 Month Rush to EHR Starting August 2012

Written by: John Lynn

As I look forward to EHR in the year 2012, it was suggested to me at HIMSS that we’re going to see an EHR adoption rush starting in August 2012. If you think about the timeline and all the other EHR happenings, I think this very much will be the case.

I saw a tweet (which I can’t find now) which said something to the effect of meaningful use attestation in January of 2012 was as big as all of 2011. I also have read about the mass of meaningful use attestation that happened at the end of 2011. With only having to attest for 90 days it makes sense why so many people waited until the end of 2011 to attest to meaningful use.

I expect we’re going to see the same rush to meaningful use attesation in 2012 as well. However, you don’t just implement and EHR and then start your meaningful use attestation the week after you implement an EHR. In most cases, you need at least a couple months (more in the hospital case) after implementing an EHR to “get your feet under you” and be ready to concern yourself with the meaningful use requirements.

With this in mind, I expect these next 3 months will be critical for EHR vendors that want to fill their Fall EHR sales pipeline. EHR adoption will slow down a bit during summer when doctors head out on vacations. Then, Fall 2012 will start the rush of EHR adoption in order to meet meaningful use requirements in 2012.

Of course, it’s also likely that many doctors will procrastinate their EHR selection process. They’ll wait until Fall and then rush through EHR selection. I think this would be a real tragedy for EHR since selecting the right EHR is the mot important part of the EHR implementation.

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The EMR Language

What Can We Do Today That We Couldn’t Do Five Years Ago in Health IT?

The False Economies of EMR

Meaningful Use the Commodity – Meaningful Use Monday

Lawsuits Will Eventually Drive EHR Adoption?

Is Lack of EHR the Real HIE Problem?

Top Healthcare IT Vendors by Revenue

Resistance to Change Will Fuel EHR Adoption

Funny Video Related to the Move to EHR in Healthcare

Predicting a 6 Month Rush to EHR Starting August 2012

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