I hope that everyone is enjoying this wonderful Fourth of July. I know I’ve had a great day so far and we’re gearing up to head to KFC and enjoy some fireworks with friends. Should be a great evening if the kids don’t get too cranky along the way.

It has been a great day for me to remember how lucky I am to live in this wonderful country. There are plenty of things that are messed up in this country, but over all the freedoms we enjoy and benefits of living in America far outweigh the down sides.

As I typed in the title of this post, I wondered what other things do I wish had their freedom when it came to the EMR world.

First thing that came to mind was data independence. How beautiful would it be if our healthcare data was independent. I’m sure the ePatients out there would love to have access to their patient data. I think they’ve made some great progress in this regard, but our systems still need to get to the point that healthcare data independence is an even bigger reality.

I also couldn’t think about the doctors that are held hostage by unscrupulous EHR vendors who are taking them for whatever money they can while they hold a doctor’s data hostage. You know what I’m talking about if you’ve ever wanted to leave one EMR vendor to go to another. There are some EHR vendors who do a great job of this, but most of them are terrible. Yes, most of them are large companies who are more worried about numbers than they are customers. Thus, the results aren’t pretty. Of course, the great companies out there realize the benefits of making the data available to users. Not to mention the trust that’s built with a customer when they know they could leave any time they want. That kind of customer first focus will carry through to all of the other features of the software. We need more data independence from EHR vendors.

I recently wrote a post on EMR and EHR about Technology Flourishing without the Chains of Insurance. I’m not sure if complete independence from the insurance companies is the right approach, but we need to allow more doctors to be free to be doctors. They need to have more independence from the insurance company requirements and more concerned about the health of patients. I’m not sure how we get there from here, but I applaud those many doctors who do this in the face of perverse financial incentives.

I’m sure there are many more. Let me know your thoughts about independence day and I hope you enjoy the holiday.

Looks like Estonia is the new model for system wide EHR http://bit.ly/liYLwe

June 19, 2011 11:27 pm via TweetDeckReplyRetweetFavorite

@boltyboy

Matthew Holt

I’m always fascinated by other countries EHR implementations. So many other countries are interesting to consider since they’re missing so many of the barriers that make EHR adoption and even more specifically health information exchange between EHR software so difficult. Nice to learn more about the success that Estonia has had adopting EHR software. I’d like to learn a lot more about what’s being done with international EHR implementations.

The difference between an ambulatory and hospital EHR http://goo.gl/fb/YDWaO

June 19, 2011 8:01 am via GoogleReplyRetweetFavorite

@kevinmd

Kevin Pho, M.D.

I often have an internal battle when writing on this blog when I’m writing something that’s ambulatory EHR specific versus Hospital EMR specific. In fact, I was struck when someone recently told me that this site focuses more on hospital EMR and not ambulatory. I had to laugh since when I write, I’m mostly writing from the hospital EMR perspective.

This stuff aside, there are distinct differences between a hospital EHR software and an ambulatory EHR software. The article linked above highlights some of those differences. Coincidentally, I’m going to be working to write more about specific hospital EHR issues on the aptly named Hospital EMR and EHR blog. If you like Hospital IT, then go and sign up for the Hospital EMR and EHR email list. It will be a nice compliment to this blog and the EMR and EHR blog. I’ve got 3 other writers that will be starting to write on that blog as well. I’m excited to learn more about large hospital EHR vendors like the mythical Epic. Plus, as I learn more about hospital specific EHR issues, I think the content on this site will benefit as well.

What happened in the M&A arena had interesting ramifications, but what didn’t happen might be equally significant: The overcrowded electronic health records market didn’t consolidate.

Well over 200 EHR vendors are fighting for meaningful use business. How crowded is the field? As of mid-April, the federal government lists 393 Complete or Modular certified ambulatory EHR products, along with 182 certified inpatient Complete or Modular products.

There were several good reasons for the non-event, but consolidation’s got to come soon, says Rob Tholemeier, senior research analyst at Crosstree Capital Partners, a Tampa-based corporate financial advisory firm. “There has never in the history of software been 200-plus companies selling similar functionality,” he notes. “Less than a dozen-maybe a dozen at most-will survive.” -Source

I always find these reports on the EHR market fascinating. I’ve done some analyst work for a few companies that are looking at the EhR market. I should probably do more since it’s pretty fun to be able to provide investors a view at what I see happening in the EMR and EHR market.

I agree with the above statement that it’s been a little bit surprising that we haven’t seen more consolidation in the EHR market. I think we can all agree that there are far too many EHR vendors out there right now. I’m all about competition, but this many competitors makes it really hard for the clinician to choose an EHR. Certainly this is going to change.

The above linked article suggests that most of the EHR consolidation would be through attrition instead of acquisition. I don’t totally agree with this theory. There will be a nice mix of both. Although, I believe that acquisition of EHR vendors will actually be more common than EMR vendors shutting down the business.

Plus, while we will see some consolidation, I totally disagree with the above quoted articles assertion that the EHR market will consolidate down to “a dozen at most” EHR vendors. I’ll be surprised if we get down to 100 different EHR vendors. The SaaS EHR vendor business model just doesn’t need that many doctors using their system to work. Unlike many other industries, I think that there’s a whole set of very conservative EHR vendors who can run their business very well with a small subset of providers.

Of course these EHR vendors are always looking to grow, but I see many of these companies ready for the long EHR grind. They’ve been very conservative in their approaches and can last a very long time with their current EHR user base. Many aren’t even trained in the thinking of how to exit the business. They’re entrenched and ready for a long battle. So, while we’ll see some consolidation of the EHR industry, don’t believe these analysts that are predicting a massive consolidation to a handful of companies.

It seems like EMR innovation has been a strong theme on EMR and HIPAA ever since I wrote about the lack of EHR innovation at HIMSS. I of course clarified my original post with this post on the future of EMR and EMR innovation and then wrote about the challenge that doctors have to differentiate EHR software amidst all the noise. I also think it’s worth noting that EMR software can be a tremendous innovation for a practice that is using paper charts. I just don’t see an EMR software that is the must go to EMR system. There’s no “iPad” of EMR software (yet?).

After careful consideration of these ideas, I can’t help but wonder if an EMR that provides innovation in healthcare is the innovation that will have an “iPad-onian” moment. Basically the EMR facilitates a dramatic change in the way healthcare is delivered. This isn’t some feature or function that the EHR company can announce at HIMSS. EMR features and functions will never be heard above the noise. EHR vendors are already saying they can do everything, whether they can or not. Instead I’m talking about a real change to the way healthcare is provided and that’s facilitated by an EMR software.

For example, is there a doctor brave enough to have an all iPad/iPhone medical practice? Their EMR software would all be in the cloud and would facilitate online visits with patients or in house patients with visits where the EMR software was easily accessible using wireless technologies. They wouldn’t even have an office. They would do half of their visits from the comfort of their homes and half at people’s houses. Would that cause people to talk? I think so. Would the business model for the practice need to be different? I think so. Would an EMR and related technology be essential to make this happen? Yes. Could an EMR company be built to facilitate this type of a medical practice? Sounds like an interesting franchise model to me.

I’m not sure if this is a good idea or not. Plus, there are certainly people a lot smarter, more informed and innovative than me that could make this type of idea even better. However, it’s becoming quite clear that building just one more feature and function isn’t going to differentiate you from the rest of the EMR companies. That’s why I won’t be surprised if the real “innovative” EMR company will likely be a startup company. They’ll likely not know very much about how healthcare is “suppose” to work. They’ll also likely be told that their model is impossible and just won’t work. Instead they’ll just focus on using technology to connect the doctors and patients in some non-traditional manner. To me, that’s the type of companies that healthcare really needs.

There’s some really good comments happening on my previous post about EMR companies with an “In” with doctors. Check it out and join in with your thoughts. One of the comments reminded me of another interesting issue with all of these EMR vendors trying to vie for your attention. How does an EMR system rise above all the noise? Or if you prefer the doctor perspective, how can a doctor notice the really innovative and useful EMR companies amidst all the noise?

This is a serious problem and sadly I don’t know a very good answer. I talked with one company who was considering going into the EMR field and they said, “We know we can create a great product that works better than those that are present. Although, if we do, will anyone even notice.”

It’s a fine question that reminds me of my post about EMR software possibly being a commodity. Maybe it’s not a commodity, but the noise of 300+ EMR companies and meaningful use relegates it to a commodity because no one can tell the difference with all the noise. Bad singers sound a lot better in a noisy restaurant.

Basically, is there anything that an EMR system could say they deliver that would rise above the noise? In fact, this is essentially the question that I posted to the new Healthcare Scene LinkedIn group (You should join). I get a lot of pitches all the time running this site, and I’m not sure I’ve seen any EMR company have an iPad-onian (my new word for how the iPad revived the tablet industry) moment.

The biggest problem with this is that EMR vendors are saying everything under the sun. Including things that the EMR system can’t deliver.

It’s going to take a couple weeks to really process all that I saw and heard at HIMSS 2011. In fact, there’s no doubt that much of the content I publish over the next month or two will be things I learned from the people I learned from at HIMSS or influenced by what I saw and heard. However, after a good night’s sleep in my own bed I’m really happy with my experience at HIMSS. The energy and passion for healthcare IT that was found at HIMSS was really powerful and wonderful to be apart of.

I think those people out there that are asking if we’re in a healthcare IT bubble right now are on the mark. There’s very little doubt in my mind that we’re in a healthcare IT bubble. It’s a feature of $36+ billion in EHR incentive money being given out by the government. I can’t remember the size of the EMR market numbers off the top of my head, but $36 billion in money coming into what is a relatively small market is going to change things dramatically. So, it makes sense that this type of infusion of money would create a bubble of sorts.

One person in their comments that we’re in a healthcare IT bubble asked if the bubble would pop before HIMSS 12 in Las Vegas. I believe we have at least one or two more years before the healthcare IT bubble pops. In fact, if you thought that HIMSS 11 in Orlando was big, I predict that HIMSS 2012 in Las Vegas will be even bigger. The EHR incentive money will have started flowing and the trench battles will be in full swing as the 300+ EMR vendors battle each other for customers.

EMR software was obviously my focus at the conference and despite my comments about the lack of innovation by EMR vendors and the future of EMR, I think there are a ton of really interesting EMR approaches that in aggregate are going to impact the EMR world in really dramatic ways. Here’s some examples:

• Azzly described a meeting of EHR vendors they attended with ONC. The question was asked which EHR vendors in the room started development after the HITECH act was announced. Azzly was the only one to raise their hand. I’m sure there’s other EHR vendors in that same boat, but it will be interesting to see an Azzly EHR that was built post incentive go up against the legacy EHR software.
• ClearPractice was the first native iPad EMR (called Nimble) that I’d seen and there’s no doubt they’ve made a big play in that space. Will that combined with the backing of John Doerr and their internet driven sales change EMR as we know it?
• Will larger companies like Greenway and Sage continue to gain market share as they go after the EMR market while maintaining their customer experience? Or will they head the way of the Misys of the world and be bought up by other EMR vendors?
• What about NaviNet‘s entrance into the EMR world? Can they leverage their existing connections with so many providers to be a major player in not just interoperability but in EMR as well?
• Even the big behemoth of a company, GE surprised me when I visited with them. There was a polish and a professionalism that I loved about my visit with GE and GE’s Centricity Advance people. I think there’s a fair comparison with Microsoft. Something about the nature of the US loves the underdog and hates the big name player. Yet, the big company just keeps executing their vision and many doctors are going to happily buy and use their products.
• What about Ingenix‘s multiple EMR offering strategy? Will it just be confusing to clinicians or will they effectively differentiate their various offerings while providing a backbone for interoperability as well? Is the future large EMR vendor one that aggregates a bunch of niche specific EMR companies?
• What impact will the transcription based EMR vendors have on the market? I wrote about the change from transcription company to EMR vendor earlier this week. Watch for the names MD-IT, FutureNet, Intivia, and MxSecure.
• Many people probably don’t recognize the name MedPlus. However, everyone knows the company behind the MedPlus Care360 EMR: Quest Diagnostics. There’s something powerful about being able to turn on an EMR in a medical practice with basically the flip of an electronic switch. That’s what MedPlus can do since Care360 is already being used in so many clinics that use Quest for their lab work. Add in their existing lab sales staff that already have relationships with large numbers of clinics and they’re going to be a very interesting player in the EMR space.
• Free EMR is a really compelling marketing tool. There’s a reason that Practice Fusion and Mitochon Systems free EMR offerings get so much press and so many doctors evaluating their EMR offerings. While many might disagree with their model or even believe that it will fail, these companies have and will have an interesting impact on the EMR landscape.
• MicroMD offers an interesting approach. First, because of their existing LONG term practice management clients. Second, because of the interesting integration with the supply side of their company. Not to mention, the executives that I met with were some of the most realistic people and well thought out people I met at HIMSS.
• Props to EMR company MIE that could use a fake EMR company (Extormity) to launch themselves into the EMR discussion while also helping to open up the discussion as well.  If I were a doctor, I’d want to demo their EMR just so I could see if I could find any Extormity features in their EMR.  Although, maybe that’s just the blogger in me.

I could keep going on, but that gives you a bit of flavor of some interesting EMR vendors and their market approaches. Plus, this is just 16 of the 300+ EMR companies that are working in this space. Each one with their own interesting story.

The most exciting thing for an EMR nerd like myself is that we’re really only at the beginning. Wait until we get beyond 15-25% adoption and reach 50% adoption. Then, the fun really begins.

Full Disclosure: Practice Fusion, MD-IT, MxSecure, and Mitochon Systems are all advertisers on this site. EMRandHIPAA.com’s HIMSS11 coverage was also 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.

Turns out that my previous post about lack of EMR innovation at HIMSS was a little more controversial than I expected it to be. Plus, I’m not sure that I communicated the entire message about EMR innovation and the future of EMR software in healthcare (I’m blaming the late nights and lack of sleep).

I’m still suffering the HIMSS hangover and on this too small to type well netbook, but let me try and add some more context to the previous post.

One person emailed me about my “disappointment with EMR software.” I’d be careful to characterize it as disappointment with the EMR industry. I’m really optimistic about the future of EMR. I still think they’re a great value proposition and that EVERY (leave a few rural settings aside) doctor should and will have an EMR and technology in their office. I guess the disappointment is mostly that meaningful use has killed some of the innovation that could have made EMR even more exciting.

One thing seems to be clear. Every EMR vendor that I talked to has conformed with the meaningful use guidelines. So, inasmuch as you see the meaningful use guidelines as innovative, EMR vendors are certainly hitting those guidelines.

Janice commented on my other post that she was optimistic because meaningful use gets content stored electronically and that will unleash the real power of technology. One thing that can’t be argued is the increased interest and focus on EMR software. That I believe will have a great effect on EMR software and I’m optimistic that doctors and clinics will generally do what’s right and best in selecting and implementing EMR software. Plus, while a little harsh to mention, doctors that are on their second EMR implementation do much better and rarely get it wrong the second time.

One vendor described it well when they mentioned that their original business was a great and useful service, but it wasn’t the heart of any clinics business. Thus their move to EMR (although, there were other reasons also). Either way, the message they sent was clear: EMR will be the heart of every medical practice.

With that message in mind, I want EMR vendors to take this to heart and improve their applications in innovative ways for both patients, doctors and healthcare in general. I look forward to seeing those iPad-onian innovations in EHR software. Just like none of us expected or predicted the impact of the iPad. I don’t know where exactly a similar innovation will come in EMR. However, I look forward to it and believe we’ll see many many iPad-onian innovations in healthcare IT.

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 most disappointing parts of HIMSS for me is that the really creative and disruptive innovations are missing from HIMSS. There are a few items I saw like the Shareable Ink technology, some of the Nuance NLP/voice recognition work, and a pretty cool biometric kiosk by Fujitsu (which I’ll blog about later). Sadly I wasn’t seeing the really creative innovation coming from the EMR companies (and I talked to a lot of them) at HIMSS. I think there’s two possible things at play in this regard.

First, meaningful use is probably largely to blame for much of the lack of innovation that I saw. As someone told me, the regulation of EHR software has damaged and deterred the innovation. I guess you could say I’ve seen some interesting and innovative ways to approach meaningful use, but being innovative in meeting a government regulation is not the innovation I want to see. I think it’s generally clear that EMR vendors have spent the last development cycle focused on EHR certification and meaningful use.

I asked one large EMR vendor about this idea and what innovations their EHR had available. I don’t think he was very comfortable with the assertion. In response, he described how at his EMR company, they had a team that was focused on EHR certification and the meaningful use requirements but that they also had a whole other group that was focused on customer’s needs and meeting those customer needs.

It’s incredibly interesting that so many EHR vendors responded to my innovation (or what differentiated them from other vendors) by playing the EMR usability or “Doctors like using our EMR” better card. That’s related to the above, we have a group that focuses on our customer’s needs.

Certainly focusing on customer requests and needs is vital. However, it seems fitting to mention the oft quoted, “If I asked my customers what they wanted, they’d have said a faster horse. – Henry Ford” Seems like HIMSS was just displaying the faster “horses” [EMR].

A second possibility is that maybe EMR software has become a commodity. Maybe the reason we don’t see that much innovation is because EMR software has now basically become a commodity. I certainly heard many EMR vendors suggest that EMR is basically a commodity service now and that many other factors will determine the success of the EMR company instead of the EMR software itself. I argue that once you reach a certain set of features, functions and successful installs that the software itself does become secondary to the success of most EMR companies. Does that mean EMR is a commodity?

The other angle that a few new EMR vendors are taking is that EMR is not a commodity. It’s just that all the current EMR software is junk. Most then like to compare EMR software to tablets. The Apple iPad came along and finally presented what amounts to an incredibly well thought out and designed tablet and is destroying the market. These new EMR vendors see their product as the innovative “iPad” of EMR software.

Only problem is that I have yet to see any EMR company have an iPad-onian moment.

I could easily argue that the iPad was the most marketed IT device on the HIMSS exhibit floor. Yet, an Apple booth was absolutely no where to be seen.

I wonder what kind of EHR could be so innovative and disruptive that it would be the talk of HIMSS even if they didn’t exhibit?

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.

As many of you know, EMR and HIPAA is a big time news company. We have a really fat budget and pay our reporters huge amounts of money to sit and smoke cigars while producing very little content of value.

One of our biggest expenses here at HIMSS is in our investigative reporting department. Our motto is that if someone else breaks a story before us, then we spend the money to break them. Yes, we’re very serious about spending outrageous money breaking stories that no one else can break.

After 3 years of investigation (and no government stimulus money), we’ve finally cracked the code on who’s behind the famous (and hilarious) Extormity EHR software. They’ve been very good about concealing their identity before their big HIMSS press conference in 312C, West Building.

The people behind Extormity EHR is actually the obviously creative and innovative people at MIE – Medical Informtics Engineering and NoMoreClipboard

Credit them for their creativity and bringing to light the atrocities that I call Jabba the Hutt EHR vendors. The good thing for MIE is that I don’t consider them a Jabba the Hutt EHR vendor like the popular Extormity EHR that they created.

More news later after the press conference and presentation at HIT X.0 on Thursday.

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.

Neil already broke the news a few weeks ago that the MTIA (Medical Transcription Industry Association) changed its name to the CDIA (Clinical Documentation Industry Association). I was able to attend the press event that they held to officially announce the change.

I’m sure that many might not think this is such a big deal. Ok, the name change isn’t that big of a deal. However, I’d say that this part of the movement that I’ve been talking about for quite a while. Basically the survival of transcription for the forseeable future.

I don’t think I talked to any transcription companies at the event that weren’t working on some sort of EMR tied to transcription strategy (MD-IT, FutureNet, and MxSecure to just name a few). In many cases they’re doing their very own EMR offering.

I do think that the small transcription provider is likely in trouble. However, I won’t be surprised if transcription companies become successful EMR companies.

There’s still quite a few question marks with this strategy. For example, how well can a transcription company that’s use to working with people transition to making software?

The good thing is that these transcription companies already have relationships with a lot of doctors who want an EMR that somehow still uses transcription. I talked with one transcription company that offers an EMR and they had an interesting way of using transcription and voice recognition to transition them to EMR while helping them to learn to get use to doing the voice recognition. Very interesting approach.

Maybe transcription isn’t the long term solution. However, I wouldn’t count out the transcription companies just yet.

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.