I have to admit, I’ve really enjoyed going through and making lists looking back on EMR and Health IT in 2011 and thinking about what is going to happen in EMR and Health IT in 2012. Thanks for everyone who has joined and added to the discussion. It’s been really great!

This next list might actually be the hardest one for me to create. I call it the 2012 EHR and Health IT Noise. You know what I’m talking about. The topics that are going to get talked to death, tweeted everywhere, but won’t really have any major impact on healthcare (at least in 2012). Some would call these distractions.

HIE – Yes, we’re going to hear more and more about HIE’s and their potential. 2012 will still enjoy all that federal grant money that was given to HIE’s. What will we see from it? Maybe a couple books describing lessons learned from all the money spent on trying to set up an HIE. If one or two HIE’s are successful and start sharing patient data with doctors I’ll be really impressed.

EHR Usability – In 2012 I predict we’re going to hear story after story about the lack of usability with EHR software. The complaints will start to pile up, but I don’t think any of that noise will do much to shift the usability of EHR software. It’s a really hard task to dramatically shift the usability of EHR software after the fact. I can’t see many of the legacy EHR accomplishing that shift.

Some new EMR startups may start to come into their own in 2012 with usable EHR software, but they likely won’t be heard above the noise of the other legacy EHR software that’s practically unusable. We’re in a selling spree cycle for EHR software, maybe 2013 will change that.

Mobile Health Apps – This is a little different noise than the others above. This will be noise because there will be so many mobile health apps out there in 2012 and none of them will really consolidate market share yet. I believe that a number of mobile health apps will start to differentiate themselves in 2012, but most people won’t know the difference. They’ll just hear all the noise and try and ignore it.

Meaningful Use – Oh wait, I already wrote about that one here. If you haven’t read the comments of that post, you should. Some good discussion.

Any other things you think will make noise in EMR and Health IT in 2012? I’d love to hear your additions.

You’ve undoubtedly heard the argument before: EHR certification is about assuring that systems meet minimum requirements for functionality and interoperability, but the certification process falls way short in terms of usability, privacy and security. But have you heard the argument from one of the ONC-authorized certification bodies?

This is an excerpt from an e-mail I received today:

Meaningful Use criteria have become a massive EHR certification driver for healthcare organizations. Hospitals and other providers rely on the criteria to ensure that their health IT systems meet minimum government-specified functionality and interoperability requirements to support Stage 1 of Meaningful Use.  Achieving Meaningful Use also ensures a health care organization qualifies for reimbursement under the American Recovery and Reinvestment Act as a way to incent adoption of e-health processes among health organizations. The ultimate goal is to improve our nation’s healthcare system by leveraging technology to allow greater access to important health information and empower patients to securely access their own health information.

However, as one of only five organizations authorized to test both complete and modular EHRs by the Office of the National Coordinator (ONC) for Health IT, ICSA Labs questions whether EHR certifications are enough as the criteria represents only minimum requirements. Amit Trivedi, healthcare program manager at ICSA Labs, believes providers should take further steps to heighten the security and privacy of their health IT systems. He also suggests vendors should look beyond the current regulations to address and improve usability, data portability, and information exchange in their products.

That’s right, ICSA Labs, one of five organizations currently authorized to test and certify complete EHRs on behalf of the Office of the National Coordinator for Health Information Technology, seems to think that the standards it tests EHRs against are inadequate, which is something that critics of certification—particularly critics of the Certification Commission for Healthcare Information Technology—have been saying for years. Critics of many of the larger vendors have been saying that, too. But it’s shockingly refreshing to hear this from an actual certification body.

In fact, the publicist for ICSA, a unit of Verizon Business, has offered interviews with executives of two lesser-known vendors,  Health System Technology and Design Clinicals, to talk about how they are going beyond the minimum certification requirements. Deadlines beckon, so I didn’t really have time to wait for the publicist to try to find me an schedule opening for one of the executives, but here’s a statement from a March 30 ICSA press release that is somewhat telling:

“This year we are expanding our certification programs into health IT, a much-needed area of focus to help modernize today’s health care system,” said George Japak, managing director for ICSA Labs. “With our new focus on safeguarding patient information within electronic health records, we are committed to helping accelerate the adoption of health IT.”

We don’t hear too much about security in the context of certification from too many other camps, so it’s nice to hear that at least one certification organization is critical of the rules it is under contract to follow. Perhaps we’ll see tougher usability, privacy and security standards in the permanent certification program ONC needs to have in place by the beginning of 2012 to support the forthcoming Stage 2 “meaningful use” requirements from CMS.

Wishful thinking?

As much as I’d like to visit DC (I’ve never been), I wasn’t able to make it out there to attend the NIST workshop on EHR usability. However, Carl Bergman from EHR Selector did make it to the event and sent the following notes on EHR usability according to NIST.  Most of the speakers name link to their slides in PDF format.

National Institute of Standard and Technology’s Workshop on EHR Usability

This week I went to a NIST workshop examining the state of EHR usability. The workshop was at its administrative headquarters, a large 60s building on its sprawling Gaithersburg, MD campus about 20 miles outside Washington.

You might wonder what NIST is doing in the EHR business? I certainly did. NIST’s mission is to promote commerce and technical innovation including methods to determine, independently, the safety and security of a broad range of technologies including software. (It’s part of the Department of Commerce.) Since WW II, this has involved looking at the human factors involved in operation of every thing from nuclear plants to robotics. Interestingly, it’s not a regulatory agency, such as, the FDA or FCC. NIST’s standards work is through consensus building among manufacturers, consumers, regulators, etc.

The workshop, attended by about 200 persons, had two parts:

•      A review of the state of EHR usability studies by academics, practioners and system administrators and,

•      Introduction of NIST’s draft for a usability standard.

Part I. EHR Usability Today. There were many speakers, here’re the ones that had the most new information for me:

•      Mat Quinn of NIST covered its approach and work with ONC on the issue. Notably, NIST has published several documents in the area such as, NIST Guide to the Processes Approach for Improving the Usability of Electronic Health Records, (NISTIR 7741) which promotes a user centric approach to design and development.

•      I was really taken by Muhammad Walji’s study using a unified framework for EHR testing. The study compared user experience with the VA’s Vista program and a prototype system. It looked at:

o   What percent of an operation was substantive and what was overhead?

o   How long it took users to reach various performance levels.

o   How much memorization tasks took.

o   How many steps tasks required.

o   Error and recovery occurrence.

o   Time to complete defined tasks.

The study then applied its findings to rework the EHRs’ structure and workflow showing potential time and effort savings.

•      Anjum Chagpar of Toronto’s University Health Network. A human factors manager for this large healthcare network, she discussed the problems of integrating various vendor products into their system and their approach to usability and user satisfaction.

•      Buckminster Fuller famously declared, “I am a verb.” Dr. Lyle Berkowitz may not be a verb, but he is at least a gerund. His presentation swiftly covered several topics from HIMSS’ EHR Usability Task Force to usability definitions to stakeholder roles, and applying metrics to see how much of the problem was the system and how much the user.

•      The VA’s Dr. Jorge Ferrer provided several key references on usability studies.

Part II. NIST’s Proposed Protocol. If the first part took a broad and free ranging approach to usability, NIST’s staff approach was more focused. After an outline of the study’s setting and approach, the study director, Lana Lowery, outlined the protocol’s goal: prevention of unacceptable medical errors. These include errors of both omission and commission, for example:

•      Writing an order for the wrong patient.

•      Prescribing the wrong dosage.

•      Omitted information causing an error.

•      Critical delays in delivery due to system design errors.

•      Errors due to incorrect sequencing of actions.

Next, came examples of EHRs allowing errors. Unfortunately, several of the examples weren’t well thought out. For example, a patient ID error showed two patient records on the screen. One had the first patient’s x-ray, but the second patient’s name. Most likely, this would be a database problem or an x-ray production error not an EHR problem.

Robert Schumacher of User Centric, outlined how the protocol would be tested. For example, review and update of a problem list or replacement of one medication with another. The plan included testing several of ONC’s meaningful use functions that had usability factors.

Part III. Workshop Reactions. The workshop finally broke into two discussion groups: one for the draft protocol and the other on consensus building. In both cases, the discussion quickly went off script. Participants were quick to criticize the staff’s error oriented protocol as too narrow. Why, for example, did the protocol focus on internal EHR processes to the exclusion of workflow generated errors?

I understand NIST has a high interest in eliminating catastrophic errors, but I think there is not enough solid evidence on the kind and extent of the problem. No one discounts the need to prevent catastrophic errors, however, much of the EHR error focus is due to anecdotal reports of computer prescribing errors. From what I read, many of these reports are both old and recycled. Does anyone know the actual extent of major errors?

The FDA has developed several systems for dealing with medical device errors. These now include the software that the devices use. Even if the FDA does not regulate EHRs, it may step up its efforts to record important errors. I’d sure like to know FDA’s findings before I started an effort to shape EHRs.

This is not to say that safety is not important in EHRs, obviously the types of errors that are outlined by the staff are major. However, I think there are three points that are missing in the NIST approach:

•      Design for Success. You can’t design for failure. You have to design for success. The object of EHRs, as with any system, must be to accomplish certain ends. If you loose sight of that, you may not make mistakes, but you also will fail your objective.

•      Risk Analysis. Risk analysis measures the impact on a given population of an action, its potential and costs broadly defined. It also specifies mitigation efforts. I’d be far more comfortable about the protocol if there were a risk analysis behind it.

•      Error Handling. There should be more thought to error handling. For example, when the stall warning alarm goes off on a plane, it doesn’t grab the stick and take control. It’s a warning, just that. Physicians should be warned if they are about to prescribe beyond the recommended dose, but they may have good clinical reason to do it.

NIST put on a worthwhile workshop. My guess is that the draft protocol is not going to survive without modifications that take into account a broader range of usability issues and approaches.

Today’s been a really interesting first day of HIMSS. I’d heard good things about the Health IT Venture Forum in past years and so I was really glad to be able to attend this year. Of course, if you’re following @techguy and/or @ehrandhit, then you’ve already read a number of my updates.

I also posted what might be the biggest news coming out of HIMSS 11 today that meaningful use stage 2 will include EHR usability.

I was impressed by the Mitochon systems presentation at the New Venture Forum. I had a great talk with CEO, Chris Riley after their presentation. I really like his vision for what they’re working to create. The more I talk with Free EHR vendors like Mitochon, the more I can see the potential of their business model. Shahid, the Healthcare IT Guy, told me that he knew of a couple other free EHR at HIMSS. I didn’t get those requests, so I’m interested to know the other Free EHR competitors. (Full Disclosure: Mitochon is an advertiser on this site)

ZyDoc looks interesting. Taking on NLP, auto coding, and transcription. Lots of competition there now. #HIMSS11

February 20, 2011 7:01 am via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

As you can see from that tweet. I was really intrigued by ZyDoc. I’ve been fascinated with NLP since last HIMSS. Combine that with the increasingly popular auto coding engines that are coming out and it’s a really interesting offering.

One of the presenters at the venture forum said the following about the hospital connectivity market. I wonder what people think about it:

Hospital connectivity market just estimated at just over $1 billion. What do you think? #HIMSS11

February 20, 2011 7:43 am via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

AiDi – EHR in China. 30,000 hospitals in China. I wish I knew the chinese EHR market better. #HIMSS11

February 20, 2011 7:26 am via HootSuiteReplyRetweetFavorite

@ehrandhit

EMR, EHR and HIT

I’ve always been fascinated with China. Add in my interest in EHR and of course I loved the presentation on EHR in China. This company is even more interesting since they have built the EHR with the Chinese character set and it seems like they understand the Chinese healthcare culture.

The Rothman score from Rothman Healthcare is fascinating. Although, there are a lot of interesting practical questions. #HIMSS11

February 20, 2011 7:53 am via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

I loved how the Rothman score tried to quantify a patient’s condition for early warning. To see the score change on a graph really does change your view of a patient’s progress. I just wonder what a hospital’s liability is if the score changes and they don’t follow the alert. I also wonder how many false positives it would produce. Some sort of summary like this has to be the future. I really hope that they’re successful.

The following tweet was the best quote by Aneesh Chopa, CTO of the US. I also loved his energy. I bet he’d be a fascinating person to have dinner with.

New incentives plus information liberation = rocket fuel for innovation #himss11

February 20, 2011 10:56 am via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

I also had a chance to meet with Shareable Ink, but I think I’m going to save my discussion of their technology for an after HIMSS post. So, watch for that. It’s really neat technology.

The increasingly famous Brantley Whittington, CEO of spoof EMR company Extormity, stopped and chatted with me. I’m still holding out on saying who’s behind Extormity, but just look for the Brantley Whittington name badge and you’ll be able to figure it out early (or check back Tuesday when I’ll post it).

I also had a good chat with Dynamic Health IT during the HIMSS opening reception. Check them out for EHR certification and meaningful use consulting. Or as they describe it, the gap analysis for hospitals interested in becoming certified and showing meaningful use. Yes, they help with the hospital EHR self-certification.

In the evening, I got the chance to meet with Dana Sellers, CEO of Encore Health Resources. I told one PR person that emailed me that I have a policy of only meeting with smart people. Dana definitely fits this category.

As most of you know, a lot of my focus is on the ambulatory EMR world and so I appreciate Dana taking some time to talk with me (and really educate me) about healthcare IT in the hospital world. One of the most incredible things they told me was that Encore Healthcare has 143 employees and they’re only 2 years old. That’s some pretty good growth for an EHR consulting company.

One thing I was impressed with was Dana’s candor with her previous company (which was sold to IBM) and now what they’re able to do with Encore Health. Dana was partially embarrassed to admit that in the previous company they worried too much about processes and not enough on getting the data back out. She did say that she thinks that Encore Health is in a much better position based on changes to technology and the environment to really get the data out of these systems so they can focus even more on the quality of healthcare that’s provided.

So much more that I could share from my talk with Dana. It probably deserves it’s on post and most certainly the things she shared with me will come up in future posts. Needless to say I was extremely impressed with Dana and so it’s no wonder why Encore Health has been so successful. I might have to stop by Tommy Bahama’s again just to hang out with more smart people.

Finally, a couple interesting tweets I saw during the show:

Discussion of tactics for dealing with detractors. Listen to them, understand their motivation. Some will be right #CDS #HIMSS11

February 20, 2011 8:53 am via TweetDeckReplyRetweetFavorite

@psweetman_live

Pauline Sweetman

and

Usability design…mobile first….Keep the common tasks easy and the uncommon tasks possible. #HIMSS11

February 20, 2011 8:16 am via HootSuiteReplyRetweetFavorite

@biomedsociety

AFBS

Isn’t it cool that I can cover sessions that I didn’t even attend thanks to Twitter?

Much much more tomorrow. Unless I’m too tired from all the parties;-)

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

In probably the biggest news of the day at HIMSS, we got the following tweet spreading quickly through the Twittersphere:

RT @afbmet Chuck Friedman from #ONC just announced that “usability WILL be in Stage 2 of #meaningfuluse at the #Usability Symposium #himss11

February 20, 2011 8:23 am via HootSuiteReplyRetweetFavorite

@techguy

John Lynn

There you have it. Word out of ONC is that meaningful use stage 2 will include some form of EHR usability. How that will be, I don’t think even ONC knows. Although, I’m sure they’ll consider looking at the EHR usability that’s already in CCHIT.

What I don’t understand is why they would do this. First, it should be part of the EHR certification and not meaningful use (maybe it was a mistweet). Why would ONC want to measure an EHR’s usability during meaningful use? That’s too late, no? Although, maybe it’s just ONC trying to collect data for other doctors that will select an EHR later? I don’t understand it.

Plus, let’s look at the EHR usability that’s been done by CCHIT. Has it really improved the usability of EHR systems?

I asked someone at HIMSS this question, and they said something like, “Of course not.”

We all want the EHR software to be usable. I just don’t understand how ONC adding it to meaningful use stage 2 will help achieve that goal.

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

One of the biggest complaints surrounding the implementation of an EMR is the way the EMR software handles the documentation method. Beyond just the learning curve, there are plenty of EMR software that have a terrible user experience.

While I don’t want to totally let EMR vendors off the hook, I do think it’s worth noting that EMR vendors aren’t completely to blame for the unwieldy interfaces. I believe one of the biggest reasons that the EMR documentation interfaces are so terrible is thanks to the crazy insurance billing and documentation requirements.

Seriously, it’s a total mess. Everyone that’s involved with insurance billing in healthcare knows what I’m talking about. Trying to code an application that’s easy to use, works well for the doctors and still handles all the insurance billing and documentation requirements is a serious challenge and so it’s not surprising why so many EMR software fails to deliver a great user experience.

That’s not to say that all EMR software have terrible user experiences. Although, let’s be honest that they’re taking on a nearly impossible task. I guess I compare the insurance documentation and billing requirements to cleaning a toilet. Nobody really likes to do either. Yet, they’re absolutely necessary jobs. Certainly there are some tools that can make cleaning a toilet easier (gloves, wands, cleaning solutions, etc). However, it’s still a task that isn’t fun to do no matter how you slice it (unless you pay someone else to do it, but the pain of the expense is still there). The billing and documentation parts of an EMR software are trying to do the same thing: make a task that no one likes easier. Unfortunately, using an EMR isn’t going to change a task that no one likes into something fun.

I hope that EMR vendors don’t use this as an excuse to not focus on creating usable software. It’s NOT! However, I think it’s important to consider the true impact of the EMR. Is it really the EMR software that is so bad or did you hate these parts of practicing medicine before having an EMR as well?

If you find that it’s the EMR software that’s so bad, then hopefully you were smart in the contract you signed with your EMR vendor (see the EMR contract section of my Free EMR Selection e-Book). You won’t be the first or the last practice to switch EMR vendors.

Of course, if the complicated insurance billing and documentation is the problem. Maybe Obamacare’s single payer insurance plan will help to solve that issue. At least there would only be one organization to deal with.

This week I saw a product demo of EMR vendor, SOAPware. Now that SOAPware has their fully integrated practice management system, they have a great demo and all the features you could want in an EMR system.

In fact, as I was watching the demo and asking questions about different features they might have or not have I came to an interesting realization. SOAPware, and most EMR vendors that have been around for any reasonable amount of time, have all of the features covered. They all have ePrescribing. They all have CPOE, and Clinical Decision Support. They all have allergy and drug interaction checking, etc etc etc.

Basically, it seems like the EMR market has matured to the point that we’ve covered all the base features that a doctor could use for their clinic. The real challenge now is going to be how usable an EMR vendor can make their software.

That’s right, Usability is going to start to trump features as a provider differentiates the various EMR software.

The fundamental challenge of an EMR software has been the time a doctor spends charting in their EMR. I don’t think that we’ve really nailed down the user interface that’s going to change this yet. Certainly there’s been some really great progress since EMR software was first launched. The iPad and other touch screen devices present and interesting alternative input method. However, I think there’s still a lot of room for some EMR vendor to dramatically change the game on how a doctor interacts with their EMR software. I’m talking revolutionary change to the interface and approach. I look forward to that day.

Full Disclosure: SOAPware is an advertiser on EMR and HIPAA, but they didn’t pay me to write this article or talk about seeing their demo.

EMR Quote of the Day comes from a comment on one of my most popular posts:

“An EMR is not a paper chart on the computer screen and as long as users think that way, complain when it doesn’t work that way, and vendors design that way… there will be issues with electronic medical records.”

I’ve been sitting on this post for a while. I figured it was finally time that we talked an interesting development in the CCHIT EHR certification: EMR usability testing. They first presented some of the details of this testing during the CCHIT training meeting. However, they also partnered with User Centric to formulate their EHR user testing and EMR and HIPAA has had a nice connection with User Centric for a few months now.

First the good. I’m glad that CCHIT is venturing into the realm of EHR usability testing. I’ve often talked about CCHIT Certification being rather useless since just because a piece of software does a certain function doesn’t mean that it does it well or that the EMR is usable. In fact, some of the most “feature rich” EMR software is completely unusable by the majority of people. Kind of reminds me of the days of terminals. If you knew the key strokes, it was incredibly efficient. However, learning the keystrokes was so much harder than a nice graphical interface which could do the same things. Not a perfect comparison, but interesting to consider.

So, the biggest problem with CCHIT measuring an EMR’s usability is that the EMR usability rating does NOT affect the certification outcome. Also, it appears that it will be up to the EMR vendor whether they want this result published or not. I wonder if we’ll get to a place where a few EMR vendors show their usability rating and others don’t. Those that don’t we’ll have to assume scored poorly? We’ll see how all that plays out.

I admit I haven’t looked over the entire EMR usability rating process. So, I can’t say if the process is complete or effective in and of itself. Although, I do have some confidence in User Centric as a company even if they’re trying to bite off the very difficult task of measuring EMR usability.

It does look like they’ll give the EMR software a usability rating that is not just a pass fail score. A rating is a much better thing when we’re talking about a somewhat abstract concept of software usability.

I’m also concerned about the quality of the jurors that they’ll use to try and measure usability. I’m sure they’re great people with great intentions. Honestly, that’s one of the most redeeming qualities of CCHIT. They have a large base of volunteers that are very well meaning. However, I’m not sure how much confidence I have in their ability to rate a software’s usability. For that matter, I’m not sure how well I’d be able to do it and I think I’m pretty familiar with the subject.

In a related issue, when you look at the way their putting together the score, it seems pretty complicated at first look. Like I said, I don’t know the details of the methodology. However, that’s kind of the point. Even if CCHIT does post an EMR vendor’s usability score, will the listening public (Translation: doctors) be able to quickly and easily understand what that score means? Maybe it’s a simple thing to figure out. We’ll see, but the devils always in the details and if I’m selecting an EMR I want it to be usable. So, I’ll be very interested in an EMR’s usability score.

Those are just a few things I noticed with the new CCHIT EHR Usability additions. Is there some other parts of it I missed? Anything else we should know about it? Will this be a valuable addition to the CCHIT Certification? Will EMR vendors revolt against it?

I’ve gotten a couple emails from people suggesting that I should write about the current and potential EMR backlog that is happening in the healthcare IT industry. It’s something I’ve discussed tangentially when talking about EMR and the ARRA EMR stimulus money. Basically, some EMR companies have been making the case that doctors and clinics need to make there EMR selection now in order to avoid the EMR backlog that will occur for an EMR vendor once we know the full details of “certified EHR” and “meaningful use.”

Dr. Jeff at EMR and EHR pointed me to a section of the newsletter by XLEMR that provides another perspective on the EMR backlog.

Once preliminary certification begins in October, EHR demand should surge. Although the market is currently slow, many vendors have installation backlogs. Preliminary certification may cause those backlogs to increase. Physicians who are in the “wait and see” mode will need to make a decision quickly. Waiting could result in long delays that may jeopardize the ability to qualify for the first year of reimbursements. One alternative is to purchase a simple system. Simple systems take much less time to install, so backlogs are not a problem. Simple systems are also easier to learn, meaning you do not use as much valuable time for training instead of seeing patients. Finally, simple systems are easy to use, giving you more time to qualify for meaningful use. Be sure to ask any EHR vendor if they have any backlogs, and how long it takes to implement their system. Their answer will tell you if their system is simple.

This type of tongue and cheek style of writing is right up my alley. It makes a really interesting point and you can’t help but laugh when you get to the end.

Some might argue that the EMR is so good that the demand for it is so high and that’s what creates the EMR backlog and not the fact that the EMR isn’t simple to use and requires a lot of training and work to implement. I’d suggest that the EMR backlog is probably a combination of high demand for that EMR and the EMR not being very easy to implement/use. However, the high demand for most of the EMRs with a backlog has little to do with how great the EMR is and has more to do with that EMR company’s ability to market and sell their EMR.