In a perfect world, an EMR vendor would be completely focused on the customer in developing their EMR software. They’d be very deliberate in their development process where they’d consider feedback from existing users while still finding the perfect balance of planning for future needs and satisfying the current needs. It’s a pretty simple concept to talk about the customer driving the development of EMR software. Yet, it’s much harder to actually do.

What makes this even more difficult is the EMR stimulus money. Ok, not the money itself, but the regulations around becoming a certified EHR and doctors needing to show meaningful use. Instead of EMR vendors focusing their development effort on what is best for the customers (doctors and patients) they will instead be focusing their development on a set of criteria that the government has imposed on them and doctors.

Here’s an example of what I’m talking about. It’s from an email I received from an EMR vendor:

At least I have a target that I can aim for. Up to now, it has just been a matter of speculation. Whether I like the criteria or not, it is now definitive and the arguments of whether it really makes a doctor productive are now academic.

Unfortunately meaningful use has started to dominate the EMR landscape and there’s no end in sight. Instead of having EMR vendors focus on creating innovative products that solve customer needs, they’ll have their focus (at least temporarily) moved to the list of government requirements. Oh, and the good news is that this is just stage 1 of the meaningful use guidelines.

If we assume that the meaningful use guidelines are the way that EMR software should be developed, then we should end up with a good result. If the meaningful use guidelines point to the wrong targets, then we’re going to have a set of EMR software that no one really wants to use.

Then there’s the reality. Meaningful use does have some good components that will benefit EMR development and healthcare in general and has a number of components that don’t make much sense at all. The problem I have is that the good components were things that EMR software were doing already. So, what are we really achieving?

Are there any EHR vendors left that plan to pave a development road map that doesn’t fulfill all of the meaningful use requirements?

My previous post about imagining an EMR that didn’t include billing certainly has driven a lot of conversation. Actually, that was the purpose of the post. I indulge in great conversation with multiple perspectives. It’s the beauty of blogging and of life.

However, please don’t let that post confuse you. Billing is an absolute essential part of an EMR software. There’s a very good reason why most EMR software out there amounts to little more than a big billing machine. The demand for healthcare software was initially to solve the challenges associated with medical billing. Markets are great at satisfying demands and that’s why the EMR software is the way it is today.

This means that EMR vendors CANNOT ignore billing. Rightfully so, doctors want to get paid for their work.

Of course, the point of the previous post was to try and expand the conversation beyond billing. Basically, the goal was to try and imagine an EMR software world where patient care was the focus instead of billing. What kind of good could we accomplish if this was our goal?

This follow up post was prompted by this somewhat disturbing email I received:
“I have built just such an EMR product for the iPhone and iPad. I am struggling with financing it because everybody wants billing. They really don’t care about the quality of the EMR.”

I’d make one qualification. No one cares about the quality of the EMR, if you don’t satisfy their billing needs too. Reminds me of HIPAA. No one would purchase an EMR that didn’t meet the HIPAA standards. However, once they hear it meets those standards, they move on to other things like the quality of the EMR.

For today’s weekend post, here’s a thought provoking comment:

Imagine what EMR software would look like if it didn’t have to worry about billing, insurance and reimbursement. Would we then see much higher quality EMR software in regards to patient care and physician workflow?

I look forward to reading your thoughts.

I was reading through a thread over on EMR Update which talks about this New York Times article. Here’s some really interesting quotes from both sources that are worth considering:

In “The Hostile Hospital,” from the Lemony Snicket “Series of Unfortunate Events” books, the three young orphans at the center of the story visit the fictitious Heimlich Hospital, where Babs, the head of human resources, asks them if they know what the most important work done in a hospital is.

“Healing sick people?” one of the children asks innocently.

“You’re wrong,” Babs growls, silencing the children. “The most important thing we do at the hospital,” she continues without flinching, “is paperwork.”

Humor is the most funny when it stabs so close to the truth.

Currently, most systems have been designed not with clinical needs in mind but to meet the demands of the fee-for-service payment system. The software rapidly codifies diagnoses and symptoms, thus facilitating billing.

No worries though. The EMR billing machines that we have now will soon be replaced with EMR meaningful use machines. {a little satire of my own}

While EMR can capture certain information like medication lists and test results with mind-boggling accuracy and efficiency, it often fails to relay the nuances of a patient’s illness course. “Physicians think in stories,” said Dr. C. T. Lin, a practicing internist and chief medical information officer for the University of Colorado Hospital in Denver, which has used electronic records since 1994. “How can you possibly point and click your way through a patient’s 10-year history?”

This reminds me of the rather compelling video I did with Mmodal where they talk about the need to have both the narrative and granular data in the EMR. I’m always amazed at a physicians ability to look at a narrative section and get the story of what’s happened. Something that lists and results just can’t do justice. As valuable as those lists and results can be in other ways.

I love the cycle that happens over and over and over again in the healthcare IT/EMR media coverage. Every 3-6 months a new study or article comes out that says that EHR Don’t Save Money. Here’s the one that I just got in my e-mail. At least this one talks about the short term issues, but leaves open the possibility of long term benefits.

Don’t worry though, in the next 3-6 months another study and/or article will be out talking about the amazing benefits of EHR software.

Let’s just cut through the crap for a second and really hit at the core of the issue.

Some clinics have implemented an EMR and seen Amazing benefits (see great EMR ROI).

Some clinics have implemented (or should I say tried to implement) an EMR and actually gotten screwed.

Every one of those cases has happened. So, if you want me to do a study or article on either side of the issue, it’s really not that hard to do. Just look around and you’ll find all of the above scenarios.

Of course the new voice I hear is that it doesn’t matter. EHR is no longer a choice. The only choice is exactly when, which and how you’re going to implement an EHR. So, that leads to what we really should be talking about…

How do clinics make sure they find themselves in the “Amazing Benefits” group?

P.S. Excuse my use of “crap” and “screwed” all in the same blog post. I just paid my taxes and I think I’m still recovering from it.

Another interesting story from EMRUpdate talking about how one EMR vendor, Medtuity EMR, took 3 locations and tied their EMRs together. However, they didn’t just do one centralized database accessed from each location. Instead, they essentially built patient data interoperability between the 3 locations. Check it out:

We just linked 3 sites in October. The docs described what they wanted, including the speed of a separate SQL Server in each facility. They also had a billing office (as the center or hub). They previously used a single server with Remote Desktop as the means of communicating with a central server. They were not entirely happy with that arrangement and so wanted to embark on a SQL Server in each facility. Additionally, they did not want all encounters synched to all facilities daily. Instead, the 3 offices synch to the billing office once daily. Pt demographics get synched from that hub outward to all offices daily just in case a pt should visit another office.

So the underlying theme was speed– each office has its own server; pt encounters originating there are stored there + at the billing office, but pt demographics are synched to the hub and from there back to all 3 facilities. It’s all automated. If a pt visits a different facility than the original, the demographics are already at that alternate site and so the additional encounters can be synch with a button press to insure contemporaneous info.

What they did not want is to have all encounters stored at each site because there is not enough cross visiting among docs to warrant it, but they did want to be able to transfer encounters quickly when the need arose.

Certainly, this problem is much easier since all 3 locations used the same EMR software. However, it seems like there’s something that can be learned from this story in regards to broader interoperability of EMR software.

Brian at new EMR vendor Health Fusion sent me an email discussing some of the posts I’d done about CCHIT certification. In the email, he talked about how many doctors would ask him if his EMR is CCHIT certified. He then told me that his response to those doctors is that it’s not CCHIT certified, but it is is “Stimulus Ready.”

I like the concept of “stimulus ready” instead of certified. First, because I think that CCHIT offers doctors no benefit (as is well documented in my previous CCHIT posts). However, more important is to consider what I think doctors are really asking.

When a doctor asks an EMR vendor if they are CCHIT certified, what they’re really asking is one of two questions (or possibly both).
1. Can you give me some assurance that your EMR vendor has a higher implementation success rate than other EMR vendors? I’ve seen far too many of my colleagues fair or heard stories of too many EMR failures.
2. Can your EMR software get me the HITECH act stimulus money?

The problem is that right now, CCHIT can’t answer either of these questions. The first question they’re likely never going to be able to say with real authority. The second one they are likely to answer at some point, but can’t do yet.

This is why I like the idea of an EMR saying that they are “stimulus ready.” Essentially that means that the EMR vendor is planning to do whatever it takes to get their EMR software certified according to the yet to be released HHS criteria. Let’s hope David Brailer is right and access to the EMR stimulus money will end up being relatively simple.

Everyone and their dog seems to be telling people that “Now is the time to purchase an EMR system.” Well, maybe not everyone, but a lot of highly visible people in HIT and many bloggers. I previously posted some of my thoughts about when to implement an EMR. However, I think many people missed the point of what I was trying to say.

Now is the time for every doctor to select an EMR software. This is not a simple process (see this 300+ EMR vendor list) and every clinic should be participating in this process. Now is a GREAT time to select an EMR software.

Plus, many, many, many clinics should even buy an EMR now. A large number of clinics aren’t going to have access to any of the EMR stimulus money no matter what they do. I work for one clinic that is in this exact situation (and you’ll love the irony that this clinic uses a CCHIT Certified EHR). At my EMR stimulus presentation, I had one guy come up and ask “So, if I don’t take Medicare or Medicaid, then there’s no money for me, right?” My answer was, “No.” (Yes, I did say there could be grants or something, but you get the point). If you’re in this position, then what’s holding you back from implementing an EMR? Go look through this list of EMR benefits and you can easily make the case to implement now. Not implementing an EMR in this case is still a mistake.

Many other clinics can easily “ignore” the EMR stimulus money and focus on the other EMR benefits. By focusing on selecting an EMR that will maximize these benefits, you can create your own EMR stimulus package. Not to mention you’ll select a better piece of EMR software. EMR software that can’t provide you those other EMR benefits is not one you want in your office even if they can get you access to the EMR stimulus money. Plus, I’ve talked a number of times about the risks in relying too much on the EMR stimulus money. There’s a lot of reasons why you might want it and try to get it but end up with nothing. Essentially these doctors are ones that can treat the EMR stimulus like bonus money. If they get it, great. If they don’t, well they’ve still gleaned the benefits of having an EMR.

Now back to my original post about waiting to purchase (note I said purchase and not select) an EMR. There are a number of clinics where the EMR stimulus money could make a huge difference in the purchase of an EMR. Many of the doctors with lower reimbursements, for example, could use the EMR stimulus money. In these cases, I think people shouldn’t be rushing things. They should ignore the calls from all angles telling them to purchase an EMR NOW.

However, even in these cases, I think it’s reasonable to finish demoing and selecting an EMR right now. If you do that, once CMS finalizes the guidelines for meaningful use and certified EHR you’ll be ready to purchase an EMR and implement. If you don’t, then it’s correct that you won’t likely have time to implement an EMR and receive the EMR stimulus money. Adopting an EMR fully takes time.

No one reading this blog should think that I’m a critic of EMR software. I am a critic of hype in the EMR industry. I’m also a critic of useless certifications and other methods that don’t provide value to doctors. I am not a critic of EMR. In fact, I’m a huge proponent of EMR software use. Done well, EMR software can be a wonderful asset to any clinic. Were it not the case, I’d have stopped blogging about EMR long ago.

One of the huge challenges that an EMR software vendor has is the long lists of enhancement requests that they receive from end users. Managing these requests has got to be one of the most challenging jobs of any EMR vendor’s development and support teams.

An EMR vendor has so many often conflicting motivations related to which enhancement requests they add to their product. I won’t go into all the details of their job here, but let’s just say they’re walking a very small tight rope. On one side, they want to be able to create enhancements that will sale more product. On another they want to keep their current users satisfied. On the other, they don’t want to make their product to specific to one area, region, specialty (unless it’s specialty specific), insurance plan, provider type, etc etc etc. Another side wants to be able to keep innovating the product in ways that weren’t suggested by the end users. Then of course each EMR vendor wants to keep some of their enhancement plans private as part of their “competitive advantage.”

Honestly, none of this is new to software or EMR. We’ve been dealing with this for a long time. However, I don’t know of any EMR company that really manages this process well. That said, I’d love to hear about other EMR vendors approaches to collecting, managing and implementing software enhancement requests.

Here are just a few of the components that I think a good EMR software enhancement request system should have:

• Simple, but complete method for requesting ehancements
• Translation of the enhancement request into actionable enhancement (this is also important for helping to filter out repeats and other such noise)
• Feedback to the end user of what was done with their request
• System for users of the EMR to see all the enhancement requests
• Method for users to be able to support enhancement requests that are already made (this helps an EMR vendor prioritize the requests)
• Method for users to provide comments on already created enhancement requests (ie. refine and improve the existing requests)
• Internal enhancement plans are part of the system
• Completed enhancement requests are noted for those interested in following the progress

As I was listing these things I think that my view of enhancement request is partially clouded by open source projects (maybe there’s an open source EMR that does the above well?). However, I think that a number of open source projects do a really good job of managing enhancement requests. The non open source software world can learn a lot from open source software in this area.

I think one of the key things I’d love to see an EMR vendor do well is involving the “crowds” of EMR users (coined “crowdsourcing”) in the prioritizing and planning of future enhancements. Users of an EMR have a wealth of knowledge related to the product and I’ve yet to see an EMR vendor tap that knowledge really well.

I think doing the above would solve a common phrase I’ve heard after doing an EMR software update: “Why did they add that feature?” followed by the question “Why don’t they add this?”

As is often the case on blogs, some of the best commentary is happening in the comments. This has never been more true on this blog than this week. The comments have been thoughtful and there’s been some really interesting back and forth discussion.

One example of a discussion that began in the comments is around the benefit of being able to be given a demo EMR system that you can sit down and try. I’m not talking about a demo of the EMR software by someone (often a sales person) from the EMR vendor. I’m talking about a real life system where people on their own can go around and try out the EMR software.

There are so many things involved in this discussion that I’ll just throw out a few ideas and let the discussion continue in the comments. Do you load the demo EMR software with data or no? In some ways it’s better to have exactly what they’ll give you so you have an idea of how much you’re going to need to configure when you get the system. In other ways it’s better to have one loaded with the configurations, a few patients, lab results, etc so you can see what’s possible.

Certainly there are some challenge with certain platforms being able to easily provide a demo install. Large organizations can often do this, but small organizations might have a harder time getting a demo install. This is harder with client server EMR compared to web based EMR software. However, with virtual machines and other technologies, there are a lot of interesting possibilities.

I know one organization actually does what they call pilot installs where they install the entire system for you and will take it out if you don’t like it. You don’t pay until after the pilot period. I’ll add in more details about this vendor in the comments. Are there other creative ways to demo an EMR vendor before buying?

Ok, that should kind of get the juices flowing. Let’s hear your thoughts about EMR vendors providing a demo system for people to “test drive” before purchasing the EMR. I’d also love to know which EMR vendors provide this and links to their demo system would be great as well.

So, those of you who have been lurking on the sideline. Check out the comments and why not add one of your own.