Time to go through some interesting Tweets from the world of EMR and EHR.

@glevin1 – gary levin
Commodization of EMR | HealthWorks Collective

There was a link on this tweet too, but it looked like a link to a page that stole the content from the original article. I’ve been intrigued by the question of whether EMR is a commodity software or not for a while now. I still haven’t come to a firm conclusion. This article uses the idea that you can buy Allscripts MyWay at Costco as a way to say that EMR is a commodity. You can also buy eCW at Sam’s Club I believe. Although, as best I can tell, that was basically a PR move on the various EHR vendors part.

Also, the article says that Allscripts MyWay product came from the purchase of Misys. Actually, I think MyWay was originally Aprima. I believe the Misys EHR software is set to be sunset.

What do you think? Is EMR a commodity?

@BrianSMcGowan – Brian S. McGowan PhD
Percent of US PCPs using EMR = 17% in ’00′ – 28% in ’06′ – 46% in ’09′ (vs 99% in Netherlands) #socialQI #progress??

The link on this one was to a terribly long PDF file. So, I cut it out. I just wish I knew where Brian got his numbers. I call BS on the US having 46% EHR adoption in 2009. I still put us at about 25% EHR adoption now. Maybe a little higher if I’m being generous. Of course, a lot of people define EHR a lot of different ways. So, that might be part of the issue.

@DRZORBA – Zorba Paster
Back to the clinic. Everyone brings their records with them. No EMR here. If they lose their record then they’re @*%&M.

Hmm…imagine a world where the doctor didn’t keep any record. The patient was just responsible for the record. That idea is fraught with trouble and issues, but I bet many doctors would love to not have to worry about the records part of their job.

@medreccom – Medical Records
“Paper is dangerous and inefficient, it doesn’t belong in health care any longer.” Future of #EMR: on.mash.to/uhVkHn

I was interested in this tweet since it linked to an article on Mashable (a mainstream tech site). So, if I get this right, this article and series was sponsored (ie. paid for) by Lenovo and profiles Practice Fusion. In other words, Lenovo paid to advertise Practice Fusion on Mashable. Good for Practice Fusion. Although, I’m not sure how many doctors read Mashable. Maybe the article wasn’t about finding doctors, but was a way to find more tech people to come work at Practice Fusion. The article itself is pretty basic for someone that reads this site. Not a bad play if that was the intent. Full Disclosure: Practice Fusion advertises on this site. Although, they certainly didn’t pay me to write about this and link to it.

A lot of people like to throw around a lot of market share numbers for EMR and EHR adoption. One thing that’s clear in pretty much every number I’ve seen (and I’ve seen a lot) is that we still have a long way to go. Across all of these numbers there’s also a few other generally accepted principles:
-Small practices have a much lower EMR adoption percentage as compared with large practices
-Specialists have a higher EMR adoption percentage than general medicine doctors
-No one knows how to truly define what EMR adoption is in a survey

Taking in all my experience reading study after study and also my experience talking with hundreds and thousands of doctors, EMR vendors, consultants, etc about EMR adoption I’d put current EMR adoption somewhere around 25%. This isn’t any sort of scientific survey or approach. It’s just my feeling based on all my experience. Some might put it a little higher and some might put it a little lower, but I’d say most of that change is likely due to how they define EMR adoption.

A question I asked a number of people at HIMSS was where EMR adoption will be after the EMR incentive money has run its course. It’s a fun discussion to have amidst all your EMR and HIT nerd friends. However, it’s also an important business of healthcare question with lots of impacts based upon how EMR adoption goes.

My personal projection is that ONC should be really pleased if they achieve 50% EMR adoption by the end of the HITECH act (approximately 5 years). A number of really smart and involved people at HIMSS agreed with me on those numbers.

Yes, so I’m predicting that we’ll see about 25% of doctors adopt an EMR over the next 5 years. After those 5 years, I predict that the EHR adoption will really accelerate and we’ll see the other 30-40% EHR adoption in 2 years. Unfortunately, we’ll probably still have 10-20% on paper for various reasons.

I must admit that 50% adoption in 5 years still feels like we’re going to be missing out on some of the benefits of widespread EMR adoption. However, 90% adoption in 7 years doesn’t sound so bad. Maybe the older I get the shorter 7 years starts to sound.

While I like the sound of 90% EMR adoption, we can still do a lot of really good things in healthcare with only 50% adoption. Hopefully, the work I do on this and my other EMR websites helps to move the needle of EMR adoption a little bit. Not to mention help improve the rate of successful EMR adopters. That’s the goal.

What’s your take on where EMR adoption will go over the next 5 years?

I recently was listening to a doctor about the reimbursement movement that’s happening in healthcare towards paying for quality instead of procedures (pay for performance or other names). He said, “It’s the right direction, but we need more research on how to measure the quality of a doctor.” Then another doctor colleague said, “In fact, in many cases the outcome that you want is that NOTHING happens. It’s harder to measure and pay nothing.”

I must admit that I’m far from an expert on pay for performance and other possible changes to physician reimbursement, but I found these two comments really insightful. I think they do a good job of describing the challenge of paying doctors based on performance is going to have in the future.

One of the major challenges is with the time needed to measure the performance before you pay the doctor. Often you can’t judge the performance until months later and reimbursement months later isn’t a good motivational model.

One thing seems clear to me about pay for performance. We’ll never even be able to really consider going to a pay for performance model without broad EMR adoption. The data we’ll need to change the reimbursement model will require the data that an EMR software can produce.

I’d love to hear what other challenges people see with the pay for performance model of reimbursement.

This recent Frost and Sullivan study (requires registration to access) has been making the healthcare IT and EMR blog rounds lately. The parts of the study that are most interesting to consider is their estimated EHR market size.

A study by Frost & Sullivan predicts that revenue for the U.S. ambulatory electronic health record (EHR) market will double from $1.3 billion in 2009 to an estimated $2.6 billion in 2012. Further, by 2013, the market will reach its peak, posting revenue of $3 billion. However, by 2016 market saturation will have occurred and revenue is expected to fall to $1.4 billion.

That’s right. They estimate in 2013 the ambulatory EHR market will be $3 billion. Now compare that number with the $36 billion of EHR stimulus money that’s available (or whichever ARRA EMR stimulus projection you prefer). Are hospitals really going to take that much of the EHR stimulus money? Something just doesn’t feel right about these numbers.

Other salient points from the study I wrote about in my posts about Complex Reimbursement as the Real Driver in EHR Adoption and the reshuffling of providers favoring Large EHR vendors.

She [Nancy Fabozzi, a senior industry analyst at Frost & Sullivan] said many physician practices are facing financial difficulties and the result is physicians are increasingly selling their practices to hospitals, entering into joint ventures with hospitals, or joining larger group practices.

“This whole reshuffling and realignment among ambulatory physicians is going to have a huge impact on the vendor market because many of these 300 vendors that we talk about are a lot of mom and pop EHR companies that have under a million dollars in sales annually,” Fabozzi said.

She added that if physician practices are going to be a part of a big hospital network or a large medical practice group they are going to buy EHR products from larger vendors.

It’s been becoming pretty clear that many small physician offices are selling off to hospitals or larger group practices. This consolidation has been going on for a while and really is going to change the healthcare industry in dramatic ways. I agree with Nancy Fabozzi quoted by Information Week above, that this consolidation favors the EHR Software that comes from larger EHR vendors. Right or wrong, hospital and large group practices generally select the larger EHR vendors.

Pat Rioux on LinkedIn made the following comment about a possible surprise that could come from the move to broad EMR adoption:

I hope the biggest surprise that we get from this huge undertaking is that we finally have providers wondering how they did their job without an EMR in the past. Improvement that is measurable speaks for itself. Patients who finally have access to their medical data and become participants in their own healthcare will be the best reward.

Well said. I’d also add that there are going to be a whole group of doctors in 5 years who never knew how to practice medicine without an EMR. There’s challenges with this too, but it’s an interesting view. Not to mention doctors who’ve been on an EMR for 10-15 years and can barely remember what it was like using a paper chart.

Yes, a few doctors will start using their EMR and miss the great chart hunt they use to embark on to find a missing chart. Or…

In a recent comment by Bobby Gladd (check out his REC Blog), he makes a really interesting connection between the need for healthcare payment reform and EHR adoption. Here’s his comment:

I would just observe that, absent significant payment reform (I won’t be holding my breath), there’s a very real problematic barrier to effective EHR use if we don’t change the basic paradigm. For example, fundamental to the concept of the “patient-centered medical home” trial initiatives now getting underway is the argument that primary care docs should properly be seeing no more than 8-10 patients per day (e.g., think about the typical hour attorney consult visit), that the customary 25-30 pts/day is driven by the need to bill, to keep the doors open; that roughly half of outpatient visits are of marginal to nil clinical value.

I and one of my REC colleagues did a clinic assessment visit the other day. We interviewed 4 docs, one of whom was a severe Dr. NO!” on the topic of HIT. His beef was basically a “productivity loss” complaint, i.e. that seeing mostly older, complex problem list pts (he’s Internal Med) made it nigh impossible to effectively chart electronically in within the scheduling constraint.

Now, perhaps with a lighter, more rational daily patient load (and more extensive EHR training) he might come around and truly “adopt.”

I consulted with an attorney a couple of years ago regarding legal guardianship over my dementia-addled (now late) Dad. The initial hour cost me $300. The entire deal ended up costing about $4,000.

A physician, however, is supposed to take in myriad data and make a comparably expert decision in 15-30 minutes — and hope he/she can eventually get reimbursed a relative pittance.

It’s crazy.

So, OK, where are we? We’re facing a current and projected shortage of perhaps 40-50,000 primary care docs, and under PCMH theory we propose to cut their pt volumes in HALF ore more so they can provide better care? All while bringing tens of millions of the previously uninsured into the (non-ER) system under Obamacare reform.

Right.

I don’t have a good answer for the skeptical docs who argue that the EMR gold rush is more about billing imperatives and vendor welfare, that the docs’ pt care-analytic needs are a distant 3rd at best.

It’s a vexing circumstance.

My only comment to the “productivity loss” complaint and the EMR gold rush that he refers to at the end is…
Maybe they’re looking at the wrong EMRs. Unfortunately, the EMR stimulus does promote mostly the wrong EMR vendors. That’s why the EMR selection process is so important.

I was really intrigued by this well done article by Dr. Richard Hom about the Ethical Dilemma of the EMR. In it he describes the difference between the EMR technology world that will “sell anything at any cost” against the medical community values of things like the Hippocratic Oath.

He ends the post with these stinging paragraphs:

But medical angst persists. Because the EMR vendor is pursuing a “top down” sell, they bypass the medical leadership and pitch the C-level administrative staff. The medical input is usually an afterthought and the medical angst continues.

Countering the medical angst and overcoming the perception of “business ethics” being ugly will not be easy. If there be a truth in medicine, it is the gaining and loss of trust. Trust is not a trivial matter that can be bandied about just for a sale. To belie the image of the untrustworthy EMR vendor, both vendors and medical professional must make this their primary goal and objective even before the first sales pitch is given. The reward is either an EMR project that is successful after two years or an unsuccessful project that lasted ten years. The shipwrecks of EMR failed projects are a testament to that result should we forget this difference in world perceptions.

I agree that trust is really the key to a successful long term relationship with a doctor’s office. The sad part is that far too many EMR vendors aren’t interested in the long term relationship. They’re making the quick sale and then looking for the next sale. I really believe that a number of EMR companies are going to quickly scale to a level of sales where they can’t support the growth and then sale off to another competitor.

However, more important might be those EMR vendors who go in for the quick sale and then leave the clinics hanging during the EMR implementation process. You all know stories of what I’m talking about. I suggest that it’s only going to get worse not better.

Add in the EMR stimulus money and the natural increase in initial (at least) EMR adoption that will occur and even many well intentioned EMR companies are going to be caught in the trap of trying to support all these EMR installs. Lack of support from the EMR vendor is going to lead to even more EMR failures.

Naturally, all of these increased EMR implementation failures will taint the EMR industry even more and slow EMR adoption worse than ever.

Not to be all doom and gloom. I’m just highlighting one possibility. What’s the solution?

1. EMR vendors don’t over sale (this will be nearly impossible and takes a special vendor to not do this).
2. Doctors, do more research about the EMR vendor you select. I call it an EMR vendor background check.

EMR is the future, but the question is how long until that future is the present.

One of the first people I talked with when I arrived at HIMSS was a meeting with Dr. Greg Parston from Accenture. Dr. Parston has an interesting job at Accenture since it seems like he gets paid to just study interesting topics. Not a bad gig.

Well, it turns out that Accenture and Dr. Parston had been working on a few studies related to EMR (imagine that). So, we had a really interesting discussion about the findings of their survey and Dr. Parston even made some predictions about the future of the EMR market. The following are some of the takeaways I thought were interesting from our discussion:

First some details about the survey. It was a survey of 1000 doctors done in December of 2009 from all over the country. They showed a 15% percent adoption rate for EMR, or basically in line with most of the other projections of EMR adoption.

The study then took a look at the next 24 months and these doctors plans for that time period. They found that 60% intend to purchase an EMR system in the next 24 months. However, if you look at just those doctors that were under 55, the number intending to purchase an EMR is 80 percent.

A few other interesting things about their motivations and size. They found that the stimulus money was the number 1 factor for wanting to implement an EMR. I guess this isn’t surprising, but it’s unfortunate. Sure seems like a hard thing to reconcile when I think that most doctors want to use technology to become more efficient. Yet, there number one motivation (EMR Stimulus money) does nothing to improve productivity. An EMR might increase your productivity, but “meaningful use” and “certified EHR” don’t help with that.

Dr. Parston also mentioned that doctors want to control their data. Imagine that! Sorry hospitals and SaaS EMR (except for those SaaS EMR that give doctors their data, I’m not talking to you).

The most interesting part of our conversation was that Dr. Parston projected that there would be 70 percent EHR adoption in 3 years. I posted that to twitter right after he said it to a mixed response with more people saying that won’t happen. What do you think about this? That’s a pretty lofty projection if you ask me. I’ll be surprised if we top 50% EHR adoption in 3 years.

Finally, Dr. Parston also mentioned that in one of his EMR studies they found that 70 of Americans said it was very important or important for a doctor to have EMR. This number kind of bothers me, because I just don’t see this same patient demand for doctors to use an EMR. You may remember that I’ve written a few times about EMR adoption waiting for consumer demand for EMR. So, I think this will happen at some point. I just don’t think we’re there yet.

I have a theory about the reason healthcare IT is so far behind many other industries. My theory on slow EHR adoption is that the tech savvy doctors have been stuck in school for so long and then stuck at the bottom of the totem poles in places where they can’t demand the use of an EHR.

My prediction is that a wave of technology savvy graduates will be the true change that will cause mass EHR adoption. As they become leaders in practices, they won’t stand for working in a paper chart deciphering illegible handwriting.

I believe this is the real hope for broad adoption of EHR software.

P.S. Seems fitting that I right about the real hope for EHR adoption on this the MLK holiday. Talk about a man who knew about real hope.