One of the more interesting dynamics in the EMR and EHR world has to do with large versus small EHR companies. I guess we’ve always loved a big versus small story ever since David slew the Giant Goliath. Plus, there’s something American that causes most of us to really root for the underdog. I don’t know what it is, but unless my team is playing I’m most often hoping that the underdog spoils the party and does something surprising. Maybe this is why so many of us love to pit the big EHR vendors against the small EHR vendors.

Personally I don’t have any particular preference for or against larger or small EHR vendors. I care more about choosing the right EHR vendor for the right situation. In some cases those are small EHR vendors and in some cases those are large EHR vendors. I only discriminate against EHR vendors who don’t perform. Many of those that don’t perform I call Jabba the Hutt EHRs. If you haven’t read my Jabba the Hutt EHR posts, you should.

Although, what prompted this post was a comment I read recently from a doctor who uses a large EHR vendor. I won’t say which EHR or who made this comment since it doesn’t matter to learn from the comment. They basically made this suggestion:I recommended a large EHR so that it can connect everything. Then he said that the large EHR vendor decreased productivity.

Certainly I realize this is only one person discussing why doctors should go with a large EHR vendor, but if I’m a large EHR vendor I’d be really upset if this is my message. And while this is one example, I’ve certainly heard it other times before.

Think about this message from a physician’s perspective. I can either go with an EHR product that decreases my productivity (Translation: I make less money) or with an EHR product that can connect everything (Translation: That’s nice, but does it save me time or make me more money?)

All the connections in the world are great, but if you hurt a clinical processes business in the process then that’s going to be a real problem. I’m a huge EHR software advocate. I think every doctor should use EHR. However, if EHR vendors continue to do EHR implementations that have a long term negative impact on EHR productivity, then physicians will continue to resist EHR software in their offices.

The good news is that I’m seeing more and more EHR vendors focused on maintaining and improving the productivity of an office during and after an EHR implementation. I hope that trend continues and that all EHR vendors become fanatical at maximizing the efficiency of a practice during and post EHR implementation.

I mentioned that I’d be doing some predictions on EHR adoption in 2012. Well, it turns out that I did a large part of my EHR adoption predictions in my Meaningful Use 2012 Predictions post. Here’s the section on EHR adoption prediction in case you missed it:

Hospitals Capitalize – My best prediction is that hospitals will see the money flowing and be unable to resist following the money line. We’ve already largely seen this shift in hospitals IT projects. I know a number of healthcare entrepreneurs who have said that hospitals aren’t really doing any major IT projects outside of meaningful use. Hospitals will continue this trend and will likely end up taking the majority of the EHR stimulus money that’s being paid out.

Small Doctors Offices Stay Away – As I wrote about previously, most EHR incentive money is being paid to existing EHR users. In 2012 we’ll be moving past those existing EHR users and I predict that most small doctors offices will continue to sit on the sideline of EHR. The money isn’t large enough for small doctors to overcome all the work required for them to implement an EHR and the EHR penalties are a drop in the bucket for most of these doctors.

I imagine that many will be thinking, “What about the other EHR benefits beyond EHR stimulus money?” To that I’d say, you’re absolutely right. There are plenty of other benefits to having an EHR that don’t include government money for EHR. Unfortunately, the free government money has created this myopic view of the world where those other benefits have lost all their appeal.

With that as background, I personally still say that we’re probably somewhere around 25% EHR adoption. I’m talking about doctors who chart in their EHR all day every day. Certainly the number is much higher if you expand it to anyone who is charting something electronically.

My ambitious guess is that we may even reach 50% EHR adoption by the end of 2012. To me this would be a huge jump, but it seems that the momentum might just be there to make that big jump. I didn’t think this previously, but an experience yesterday at my wife’s OB/GYN has me thinking that EHR adoption may come quicker than I think. Although, it also firmed up my idea that after this wave of EHR adoption we’re going to hit a nasty wall.

A Little History
First let me tell you that my wife and I have been going to this OB/GYN for about 6 years. She’s an older physician who we love. I think that love happens after a miscarriage and two healthy babies. Being that I was working in the EMR field, every time my wife’s gone for an appointment I’ve asked this doctor what she thought of EMR. I believe in our first encounter about 5 years ago her response was something like, “I’ll never do an EMR. I’m good with my paper charts.”

With our last child (he is now 2.5 years old), I mentioned that there was some free government money for EHR. Her response stuck with my wife and I. She literally laughed one of those spontaneous can’t stop laughs and then almost to herself said, “Free money for EHR…*more laughing.”

Needless to say she wasn’t that interested in EHR or any free government money.

Yesterday’s Visit
My wife had another appointment with the OB/GYN yesterday and I decided to tag along. Yes, I mostly just wanted to poke her about EHR use again to see where she was when it comes to EHR and hear her perspectives. She came into the room and said something about not having my wife’s full chart and needing to get it out of storage. I saw the perfect opportunity and so I asked her where her EHR was. She responded, “We have an EHR.”

I was a little taken back by her response. First, because she was so anti-EHR before. Second, because she what seemed like a relatively full paper chart in her hand and was asking for the old paper chart to be pulled from storage. I then prodded some more and said, then where is your EHR? She said it was in the hall. She saw 7 patients an hour (did I hear that right?) and there’s no way she could do the EHR and keep that productivity. I then asked her when she did her charting in the EHR, after hours? She kind of nodded with those stares that mostly says, “I still haven’t figured out how I’m going to get my charting done in the EHR.”

When my wife and I were heading to leave, my wife’s doctor asked what I believe was a nurse in the office which EHR software they were using. Yes, she knew the name of the company, but this EHR company has 6-8 EHR software (I bet you can guess which one) and she didn’t know which one they had. The other lady was going to pull up the EHR so I could see, but the EHR was down. Needless to say, I knew the company and the product quite well. In fact, I have an an entire thread on EMR and EHR about this EHR company with people complaining about it.

As we were leaving, my wife’s doctor said, “I hate EHR. It makes me feel like I’m crazy.” (as she held her hands up next to her head in the universal sign for getting driven crazy) Then she pulled out the “Sucks” word as she referenced her EHR vendor.

As I say above. This story just reinforced my view that many like this anti-EHR doctor will adopt EHR in 2012, but if others experiences are anything like her experience then we’re going to hit a massive wall.

For those wondering, my wife’s appointment went well. At her next appointment I’ll have her leave my business card and see if I can do lunch with her doctor some time to get the rest of the story. I want to ask her what she thinks of Meaningful use! lol

As is now tradition. Some EMR and EHR tweets that are of interest this weekend.

@linejboise
James Lineberger
2011 EHR Adoption Rates #EHR #EMR #Health IT bit.ly/uQS7VP

They put EHR adoption at about 50%. Remember these numbers are from the CDC. I think they’re being generous. I’d still put adoption at about 25-30%

HHS extends MU Stage 2 deadline to spur faster EMR adoption | Healthcare IT News: http://www.healthcareitnews.com/news/hhs-extends-mu-stage-2-deadline-spur-faster-emr-adoption

I know I wrote about this before. Now it’s official. So, I guess there is some small advantage to showing meaningful use in 2011 instead of waiting until 2012. Although, not much.

Now a great series of tweets that discuss the bain of many IT people’s existence: IE

@chukwumaonyeije
C. Onyeije, M.D. MFM
I still can’t believe why ANYONE would use Internet Explorer (unless they were forced to by IT geeks at gunpoint…)

@faisal_q
Faisal Qureshi
@chukwumaonyeije …or EMR vendors that use the IE engine within their own app

@chukwumaonyeije
C. Onyeije, M.D. MFM
@faisal_q Funny that you should mention… I’m working with a hospital based EMR that goes NUTS in Chrome. #EMRFail …

The internet would be a lot better if IE weren’t around. Yes, I’m a huge Chrome fan myself.

I was chatting with the VP of Marketing from GE at MGMA recently and he made a good analogy. He said that the current EHR environment feels like being at a pool party. Everyone’s in their swimsuits, but they’re waiting for someone else to jump in first.

I think we’ve all been at a pool party (same thing happens on the dance floor too) where we’re waiting for someone to start, but once someone does everyone else joins in. I agree that for many the market kind of feels that way. There’s very little doubt that the HITECH Act has increased interest in EMR and EHR software. The number of people looking at and considering EMR and EHR software has got to be at an all time high. However, so far we haven’t had enough people jump in (buy and implement an EHR) so that everyone else will follow.

I’m sure we could think up a lot of reasons why this is the case. I guess many of those standing on the sides are waiting to hear from others if “the water is too cold.” This analogy goes well with my belief that the early meaningful use and EHR users are going to have a strong effect for good or bad on the next wave of EHR adoption. If those that have jumped into the proverbial EHR waters enjoy the experience and find that it’s not “too cold,” then I’m sure that many others will jump in as well. If the first to jump in jump right out or look like they’re having a miserable time, then we can expect many of the others to stay on the sidelines.

I think it’s still a little bit too early to tell how the first meaningful use EHR adopters are doing and what their message to their colleagues will be. So far most of the meaningful EHR users were those who adopted EHR long before the HITECH Act. I’m waiting to hear from those who started adopting post-HITECH Act. Then, we’ll have a better idea of how EHR adoption will progress going forward.

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.

Much ink has been spilled discussing why physicians are resistant to adopting EMRs.

The thing is, it’s really no mystery.  Researchers have arrived at what seem like sensible answers to the question, including a) problems changing their work habits, b) fear of the unknown and c) struggles with kludgy interfaces.

So, why not take these problems on directly? While we can’t get inside clinicians’ heads and tell them how to think, we can address their issues concretely.

If the anecdotes I hear are accurate, many are pushed into EMR use and forced to do all the adapting, rather than getting the help they need.

So how can we help?

Obviously, physicians and other clinical staffers need access to accessible, intelligent training — ideally, both Web-based and live — as well as easy-to-use documentation that’s written in very simple language.

But that’s not all. While many institutions breeze by this step, IT departments (or consultants) should do everything they can to customize the EMR experience for individual clinicians. (If your EMR is too rigid to allow for this, that’s another story, but let’s pray you have one with some flexibility built in.)

It’s also important to pinpoint what other frustrations clinicians may have. For example, some doctors who type poorly are immensely frustrated by using EMRs, something keyboard-savvy techs might never consider.  A good old-fashioned typing course might work wonders in those cases.

In the rush to deal with the complex technical issues involved in EMR integration, it’s easy to blow by the needs of individual users.  It’s even easier to throw some fragmentary training at clinicians and assume they have a bad attitude if it doesn’t “take.”

The truth is, though, that nobody can afford to be short-sighted about getting users connected to EMRs.  Let’s hope everyone bears this in mind as the main wave of rollouts begins.

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 figured it was about time for me to do a post updating one of my top posts from 2009. This was a post I posted on February 19, 2009. It was REALLY early on in our understanding of the HITECH act and EMR stimulus incentive program. In the post, I predicted the Big Winners of the Obama EHR stimulus program. Let’s take a look at this list, see if anything’s changed and look at new additions to the list.

First, I loved the premise of my original post that with the government spending $36 billion (in the previous post the estimate was $20 billion) there have to be some people who dramatically benefit from the spending.

Here’s a look at my original list of Big Winners and my thoughts today:

• EHR Vendors – In the short term I think that EHR vendors have taken a real hit. While we waited for the government to define meaningful use and certified EHR there was a dramatic slow down in EHR adoption. Now that we’re coming out of that funk I can see a lot of excitement and energy out of the EHR vendors. I predict this HIMSS is going to be absolutely electric. It’s easy to note that interest in EHR software has increased thanks to the stimulus money. This interest is going to spill over to every EHR vendor out there. Some will do better than others, but all will start seeing some sales now. Long term, those that provide the best service to these initial adopters (or cash out first) will be the long term big winners.
• Health Care IT Consultants (ohhh…maybe I should become one) – First, I’m not likely to become a consultant any more than I am now. This blogging gig is far too good. Although, I’ll keep that in my back pocket. Me aside, the good healthcare IT consultants I know have a lot of work. Some have changed their names to meaningful use consultants or EHR certification consultants, but overall they’re doing well. A bunch are also working at RECs which doesn’t seem like a bad gig at all (as long as they meet their targets).
• Existing EHR Users – I still see them winning. The doctors I know with an EHR are loving the idea of the EHR stimulus. First, it doesn’t matter too much to them if they get it or not. Second, they see it as something that likely won’t take that much effort beyond what they’re doing now. We’ll see if they change their minds once they get into the nitty gritty details of meaningful use. They might find changes for meaningful use harder than they think.
• CCHIT (if they get chosen) – Well, CCHIT wasn’t chosen. Although, CCHIT made a really smart move to do the Preliminary ARRA certification as a way to basically lock in most of the top EMR vendors to their EHR certification. I guess I don’t see CCHIT as the big winner, but still a winner. EHR certification is still a requirement and will be for a while to come, so they still are in business. They just finally have some competition.
• Hospital Systems – There’s just far too much money available for them to ignore the EMR stimulus. Not to mention the penalties are meaningful at the scale they have. I guess I can see this going both ways. Those hospital systems with great leaders and effective organizations are going to do very well. Those with less effective leaders and poorly run organizations are going to have issues.
• Health and Human Services (HHS) – Maybe I should have said ONC or the healthcare IT portion of HHS. It’s an exciting time for healthcare and I think Blumenthal has worked hard to do things right. It is government work, but I applaud what seems to be some real sincere effort.
• Obama’s HIT Donors – I’ll leave this one alone.

Now for a quick look at the other winners that I might not have considered almost 2 years ago:

• IT Companies – I’m not sure why I didn’t consider this, but I’m amazed at how many IT companies out there are helping with EMR implementations and their businesses are benefiting from the EMR stimulus.
• HIE – It’s a bit early to tell exactly how this is all going to play out, but the EMR stimulus and meaningful use requirements have extended the life of a bunch of HIE companies. Not to mention many have been acquired because of all the activity. It’s a good time to be an HIE company.
• Trade Organizations – I think many organizations have seen all this buzz around EMR as a great opportunity for them to expand their services. It’s amazing how many different trade organizations have gotten their hands into the EMR world.
• EMR Bloggers – Let’s just say, the EMR stimulus money has worked for my family. I’m thankful for that!

I’m sure there are probably others I’m forgetting. I tried to convince myself that doctors and patients should make this list, but couldn’t find a way to do it. Certainly some doctors and patients are going to receive the benefits, but I fear that many practices are going to select the “Jabba the Hutt EMR software” that is large, powerful and difficult to use and regret it. I hope I’m proven wrong.

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.

The Physicians’ Reciprocal Insurers (PRI) recently posted the results of a survey they did of 500 physicians regarding Electronic Medical Records (EMR) software and the EMR stimulus money and penalties. Here’s one of their most interesting findings about EMR implementation:

One significant finding was awareness of financial incentives and penalties for implementing EMR systems. While 85 percent of physicians were aware of the financial incentives for implementing the systems, more than 35 percent did not know that they face government-assessed financial penalties for not complying. The penalties are equal to a one percent reduction of the physician’s annual Medicare payments per year up to five percent. However, those penalties do not seem to be having the intended effect, as more than 65 percent of physicians who were unaware of the financial penalties said this would not cause them to implement EMR.

So, most physicians are aware of the financial incentives of implementing an EMR. This was a bit of a surprise for me, but I guess not a HUGE surprise. The more interesting part is the 35% of physicians that didn’t know about the Medicare penalties and that the majority of those people didn’t think that penalties would cause them to implement an EMR.

Does this mean that doctors won’t be implementing EMR? No, I think that we’re going to see a big uptake in EMR adoption over the next two years. One thing the HITECH act and EMR stimulus money has done is increased the awareness of the good and bad of EMR. This increased awareness will be a great thing and will spur EMR adoption.

What this poll shows is that the EMR stimulus is out of touch with what physicians and medical practices think is important. The real driver for EMR adoption won’t be a government handout. The real driver for EMR adoption will be hundreds of doctors implementing EMR software which makes their life easier, increases their reimbursement and solves the physician pain points. EMR vendors that provide these benefits to their users are going to be in a great position going forward since that’s what doctors consider meaningful use.