Today I opened up a web browser and eventually made it to Twitter to see what was going on. I was greeted by the not so friendly Twitter site redesign. If you’re on the Twitter page at all, you won’t miss it. To be honest, it felt like going to a foreign land. I use a number of tools for Twitter, but my favorite is just going to the Twitter website to consume and send my @techguy tweets. Although, maybe I should say it WAS my favorite place.

Yes, change is always hard, but isn’t that kind of the point? Was there any announcement about the change before it happened? Nope! Did they give users a chance to try the new interface before they made a wholesale swap to the new interface? Nope. Google’s actually done this really well recently with things like Gmail. They’ve made the new interface available, but you can always click back to the old interface if you don’t like. That way they can solicit feedback and improve the new interface while still not alienating those that love the old interface.

In my example on Twitter, I quickly was able to identify the thing that annoys me most. When I click on someone’s Twitter name it gives me a pop up box for that person. Before it use to have that appear on the side. It’s a small subtle change, but makes a huge difference since on the side I can continue consuming tweets, but in a pop up box I have to remove it before I continue on.

I could go on about the new Twitter, but the point is that software vendors have to be careful when they change the user interface. Maybe this new Twitter interface will even grow on me. I didn’t like the last time they changed the Twitter interface either, but once I found some of the secret features I came around for the most part. Maybe I’ll come around on this too, but it would have been nice if I knew it was coming.

What does this have to do with EMR?

The connection seems quite clear to me. EMR and EHR companies have to be really careful and considerate when they change their EHR interface. Give users options to be able to try it and to adapt to it over time. With a sort of limited opt in release of a new EMR interface to an active user base, you’ll likely get a lot of pointed feedback for the new EMR interface. Certainly you’ll get the useless “I hate the new look” emails without any value. However, you’ll also get the pointed emails that provide constructive ideas on things you probably didn’t realize were important in the old EMR interface.

Most SaaS EHR companies are constantly considering this since they’re rolling out changes to their software all the time. Client server based EHR software also takes it into account, but this can be shown and taught as each client is upgraded.

The main point is to be thoughtful of and upgrade to your EHR user interface. Get feedback and whenever possible let them opt in and out of the new interface so you don’t alienate your users.

While I may not be totally enamored by the new Twitter interface, I do always love new features in software. For example, as part of the new Twitter interface there’s a feature that lets you embed tweets. Here’s a few EMR related tweets to see how it works.

Need marketplace to reward good design & doc reimbursement for social@jacthong @AtlasMD How to close gap between EMR & consumer tech? #hcsm

— borborygmi (@nickgenes) December5, 2011

And then some big news from GE and Microsoft that just came out:

G.E.-Microsoft Venture to Create ‘Windows’ for Health Care. #ehr #emrnyti.ms/u8ttTu

— Andrew Herman Heller (@andrewhheller) December8, 2011

Hmmm…still looks like they have some work to complete on their embedded tweets (UPDATE: The preview looked different from when it’s posted. It’s not too bad in the actual post). Sounds like many doctors talking about EHR features that get rolled out.

One of my all time favorite posts I’ve done was called “Develop Your Own EMR….Are you Crazy?” Hard to believe that was back in May of 2006. I should go back and check out the content of that post, but the title still rings very true to me. Of course, every entrepreneur that I know is a little bit crazy, so it should come as no surprised that I’m hearing all the time about new EMR software getting ready to hit the market.

Today’s encounter has to be one of the most unique. I was going to church in another state (visiting family for the Holidays) and I ran into one of my high school friends at church. We caught up and I learned that he’s the owner of a software development company. Then, as he learned what I was doing he just mentioned off hand that they were developing an EMR.

After I picked myself up off the floor, the meeting at church started so I didn’t really get a chance to talk to him. Since he’s my friend on Facebook (you know, a real friend that I know in real life type of Facebook friend), I sent him a message and hopefully we can connect. I’m really intrigued that his software development house is doing an EMR for someone. Obviously, now I have a ton of questions for him about the project. He did say before the meeting started that “it’s a BIG project.”

Of course, the message here is that there are a lot of people out there that are crazy (no offense intended) enough to start building another EMR. The problem is that there are so many doctors that are dissatisfied with the EMR software that’s out there, I’m sure until that’s resolved we’ll see more and more EMR software entrants. Oh, if only these brave souls knew what they were getting themselves into. I guess maybe that’s the beauty and key to entrepreneurship and why I love it so much.

There’s a really interesting article on Nextgov that talks about a CSC report that looks at the role of health IT and EHR software in Accountable Care Organizations (ACOs). The most valuable part of the article is this list of items that an EHR must enable or allow to support an ACO:

• Clinical information and point-of-care automation, with integrated ambulatory and inpatient records and a central repository for clinical data.
• Enterprise master data management and integration, with a population management repository, a master person index and a master provider index.
• Tools to enable participation in a health information exchange.
• Patient engagement tools, including secure messaging, e-visits and tele-visits, social media, patient portals and mobile health applications.
• Care management and coordination tools, including referral and request tracking, provider-to-provider communication, medication reconciliation and case- and disease-management applications.
• Performance management tools, including integrated business and clinical intelligence and analytics.

To be honest, as I look through this list of EHR items, I can’t say that any of them really stick out to me as impossible for any EHR to achieve. In fact, I’d say that they’re quite achievable by almost all EHR software vendors.

The only partial fear I have reading through the list is that some of the points depend on an EHR vendor working with other EHR software vendors. In most of the cases, these are large hospital EHR vendors that have often worked in very closed environments.

The reason this is a cause for concern is that even the best EHR software in the world won’t be an effective ACO and won’t meet the above requirements if the large EHR software vendors don’t work with them to connect their system.

Maybe this isn’t something we should be too concerned about since the hospital client will be motivated to get their EHR vendor to work with the other even small EHR vendors in order to make the ACO happen and get access to the extra reimbursement. However, my gut tells me that this won’t be the case and there will be stories where EHR software is basically shut out of the ACO based on the large EHR vendors decision to not work with them.

A little while back I asked my wife what she would do with all my blogs if I was hit by the proverbial “bus.” Her answer made me laugh. She said, she’d log into my blogs and post that I had passed away and that if readers of the site would like to support my wife and kids they could do so using the PayPal button below. I guess it’s a good thing I taught my wife how to blog. I hope she never has to post that PayPal button.

However, I’ve always loved the question of “what are you going to do if they get hit by a bus?” The “they” can be replaced by all sorts of things. Each organization will have a different set of “they’s”. Remember that the buses can come in all sorts of ways: re-location, new job, injury, illness, change of lifestyle, etc etc etc.

For example, if I’m a clinic and I have one doctor that is our EHR master, I might ask the question of what our clinic will do if that EHR master is no longer around.

How do you solve the problem of individual knowledge? I’ve seen it best approached in two ways: dual training or documentation. Personally I prefer the later to the former. Unless it’s a task that multiple people can perform regularly. The problem with dual training is that you train someone on how to do it, but if they don’t get to do it for a long time to come then they’re very likely to forget. That’s why documentation is better than dual training in most instances. Plus, once you have the documentation, you can use it to perform the dual training. It’s a great way to test how good your documentation really is.

These same questions apply to the EHR vendors that read this blog. How would your EHR software do if a key person in your organization was “hit by a bus?” We could also look at it from an EHR selection perspective. How would your EHR support be impacted if your EHR vendor lost their main EHR support person? What if the lead developer of the EHR left the company? This is sometimes hard information to obtain, but these were questions I knew the answer to with the EHR I supported for over 5 years. These are things worth considering.

How cool would it be for an EHR vendor to do a blog post about how they’d answer the question of how they’ve prepared their organization for the “hit by a bus” problem? I’d respect that EHR vendor: warts and all.

UPDATE: In case you couldn’t tell, this was an April Fool’s joke.

Over the past year myself and the other people here at EMR and HIPAA have been working like crazy on a very exciting new project. We’ve obviously seen first hand the many doctors that are dissatisfied with their current EMR and the current EMR vendors. We kept wondering how we could fix this problem. In the end, we decided that the best way to solve this problem would be to fix this problem ourselves. So, I’m really pleased to announce the launch of a new EMR software product by EMR and HIPAA called DoctorEZ (cool name huh?).

We’re still in beta right now working with only the best doctors we know to refine the product. Although, here’s the goals for our EMR software:

• No Cost for the EMR – Why should doctors have to pay for software? Haven’t you ever heard of a free lunch? That’s what we’re offering here.
• Zero Implementation Time – If you think you want DoctorEZ, it’s already installed. Doctors don’t want to take the time to implement the EMR software and so we decided to take out the implementation time.
• No Training Needed – Doctors have an MD after their name. That means they were basically professional students for most of their life. Why burden them with more training? That’s why we don’t.
• Universal Device Domination – Some people like their iPad. Fine we do that. Blackberry Playbook. It’s not released, but we support them too. Desktop. Check. Laptop. Check. iPhone, Droid, Blackberry, iPod touch, Pay as you Go phone. Check, check, check, check, check. Xbox, PS3, Tivo and Wii. You got it!
• Standards Based – SNOMED, ICD-9, EZ, ICD-10, 23%, ICD-11, SMRT, ICD-666, CPT, 1040-EZ, 5010, 90210, ACO, 867-5309, ieee, HAL-0999, etc. You bet!
• Supports All Specialties – Some people like to say that specialties have different needs. Not with the DoctorEZ EMR. It satisfies every specialty with a unique Specializer (TM) system.
• Easy – Did I mention that this was easy? (That’s why we called it DoctorEZ after all)
• Interoperability – As if other EMR are sophisticated enough to integrate with us.
• Increase Billing – Of course we do. Why else would you buy us? It’s not about the patient after all…speaking of which…
• Patient – We thought about some great features to help patients, but our beta test doctors asked us why. They then told us patients were a dime a dozen and it was all about the reimbursement. At DoctorEZ we listen to our customers.
• Interplanetary Hosting – I’m sure many of you are wondering if the new EMR will be a SaaS based EMR or client server based EMR. We decided since we were offering this for free that neither of those options was good enough for our doctors. Instead we launched a new interplanetary hosting option. That’s right. Your EMR data will be safely stored on our own personal network of data centers located on Mars, Saturn and Venus (we tried Pluto, but it lost its planet status and so we had to change direction). We had Neil Armstong sign a HIPAA business associate agreement, so you’re all covered if he heads to Mars and happens upon your patient’s info.
• EMR or EHR – Maybe you missed the part above about patients. Plus, did you see us use the word EHR in this article. I didn’t think so.
• EHR Certification – Are you kidding? Of course we are. Our business wouldn’t survive without it. Although, since we’re not an EHR we had to create our own certification called EZ Certification. Let’s just say it was easy to do. Will it get you access to the government handouts for EHR? Probably not, but you didn’t pay for the EMR and we didn’t pay for the EMR certification so it all works out. You will get to put up an DoctorEZ Certification sign on your door with our cute little bunny rabbit logo.
• Support – We’re from Las Vegas, the city that never sleeps. Neither do our support people. That’s why we’ve spared no expense on chaining them to their chairs and installing the shock collars to make sure they don’t sleep. In fact, the top DoctorEZ EMR feature is the “Shock My Support Person” EZ button.
• EMR Usability – At DoctorEZ we alpha tested a direct brain to EMR input. Basically if you think it, we record it. Only problem was we found out what the doctor was really thinking. Let’s just say I was surprised how many doctors play Farmville. To solve this problem, we’ve integrated Farmville into our EMR in a really fantastically usable way. Now doctors are no longer distracted thinking about Farmville since they’ll actually be playing it.
• Doctor Flattery Module – How many other EMR software really focus on the doctors? We’re taking it to a whole new level by randomly displaying a flattering comment about the doctor on the screen. In back office mode, a lovely male or female voice (configurable) will sound to compliment the doctor on their incredible skill, beautiful hair or amazing technique. Repeat Compliment button is available.

There’s so much more to the DoctorEZ EMR, but I think you get a feel for where we’re going. Who’s ready to sign up? Sorry. We’re in beta. However, I do like a nice piece of Cheesecake with hot fudge on top from Cheesecake Factory *wink* *wink*.

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.

Likewise, says Allscripts’ Tullman, “today we’re building the operating system for the future of healthcare. This country can’t afford its healthcare system anymore, so something’s got to change. We can no longer buy our way out of the problem.” – Source: Information Week

The above comments sparks all sorts of interesting thoughts and questions for me. The first is “What is the Operating System of healthcare IT?” Obviously, we’re quite sure Tullman hopes that it’s the suite of Allscripts products. Although, how ironic is it that one company can have 5-10 (I lost count) different EMR software. I’ve never known an operating system to have 5-10 completely different software. Seems like something needs to change there. Unless you want to say that various segments of healthcare IT are going to have different operating systems.

I do feel like EHR software is the operating system of healthcare IT. It’s going to be the basis upon which many other software packages are built on.

I imagine the above statement is probably why Tullman made the comment and the comparison. Allscripts has an ambitious project (although I haven’t seen many results yet) to create a kind of app eco system for healthcare IT apps. There are other vendors that do the same. For example, I know that SRSsoft has open API’s that allow developers to extend their apps. I love this movement in the EMR world. My biggest challenge is identifying the application developers that are interested and willing to leverage these APIs. That part of the app ecosystem seems to be missing to me.

My next thought is that similar to how we didn’t realize how beneficial an application like Excel would be until we had the operating system that facilitated its creation. Who is going to create an Excel like app that can run on the EMR operating system and provide benefits to claims processing, clinical decision support, diagnosis help, insurance billing, etc etc etc. Certainly it’s possible that the O/S (EMR) developers will make a lot of these applications, but I won’t be surprised if the EMR is just the platform that allows other smart people to innovate on a particular subject.

In my time writing about EMR, one thing has been very clear. You can’t be all things to all people. An EMR vendor that embraces, supports and creates a strong healthcare IT application developer community would cause me to take notice above the noise.

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.

Natalie Hodge MD posted an interesting list on Quora of what she considers a strong EMR system:

I am a pediatrician. Here is what I must have in 2011.
1. Usability. When I say usability, I mean I decide the definition of usability.
2. Patient Health Record. nuf said.
3. Lab interfaces that help my patients get convenient and timely blood draws that flow directly into their medical record.
4. Eprescriber that is easy to use and hosted within the same platform so I don’t have to worry about a third parties server being slow.
5. Secure messaging.
a. I need to be able to email patients in a secure fashion, and they need to be able to email me.
b. Text. I need to have secure text messaging visits with patients.
c. Video. I need to be able to do video visits with patients at times.
d. I need to be able to communicate with my team securely.
6. Inbound fax that brings any external communication directly into my emr system. Seriously it’s 2011.
7. Ecommerce. I do membership practice so I can’t be running to the bank all day long depositing checks.
8. Web based. I have to work in a web based world, because I don’t like the expense of maintaining servers and I have to be able to access my data from anywhere.
9. Iteration. I have to have a rapid feedback loop with the developers of the application. If I can’t continually give feedback that makes the emr better, then I may as well go buy an old dell desktop computer from 2004 and start using that.
10. Mobile. I must be able to access all of this on my mobile, right now, I’m Iphone 4 but next week I might be android.
11. Open. The EMR must continually create further opportunities to help physicians manage health of their patients, whether it’s by integrations with loseit.com, imoveyou.com or nike training camp’s iphone ap. Self tracking may be a key tool physicians may use to solving our nation’s health crisis.

So what I am saying is I have to be able to function in an entirely paperless loop, despite the distractions of reform, medicaid, medicare, meaningful use, and payors.

I’m sure many will have a lot to say about this list. Here are a few of my comments:
1. I wonder how Dr. Hodge defines usable. Of course, that’s the problem. She wants it usable, but likely can’t really define it.
5. I love a number of these ideas. Just a few HIPAA/security issues to deal with. Back in March 2006 I wrote a post with the idea of just having the full video recording from a visit in the EMR. I think it’s the long term future of healthcare. It is interesting that in many companies they want more video recording to protect them from liability. In other cases like many in healthcare, they don’t want video recording since it adds to their liability. I’ll be interested to see EMR vendors text message strategies going forward.
7. You don’t like the checks? Imagine that. Online bill pay. Amazing!
9. This is INCREDIBLY INCREDIBLY valuable. It’s one of the reasons why a smaller, but stable EHR vendor is often more desirable than one of the big name EHR vendors.

What do you think about this list? Is it reasonable? What’s it missing?

I’ve now had two people send me links to a study coming out of Stanford University that says that EHR software doesn’t improve patient care in the US (Here’s one story about it from Reuters). So I figure that it must be a topic that my readers would enjoy me discussing. Here’s a portion of their summary:

A team from Stanford University in California analyzed nationwide survey data from more than 250,000 visits to physicians’ offices and other outpatient settings between 2005 and 2007.

They found electronic health records did little to improve quality, even when there was “decision support” software that gives doctors tips on how best to treat individual patients.

I’ve always found it a bit off to talk about EMR software as a means to improve the quality of care that a doctor provides. For the vast majority of healthcare, more information, clinical decision support, drug to drug interaction checking, drug to allergy checking, etc aren’t going to improve the care a doctor provides. First, because the doctors have been well trained to do many of these things already. Second, because if I come in as a generally healthy patient with a common cold, then of course the doctor doesn’t need any of these advanced EMR functionality.

Now in more advanced and complicated cases, there is potential that an EMR software could offer some benefit. I remember a doctor commenting back in 2009 on my blog about how the Body of Medical Knowledge could become to complex for the human mind to process it all. Whether we’re there or yet, is open for debate, but the concept is interesting. Although, this still only applies to the outlier cases.

I remember one time hearing a clinician tell me about how the Drug to Drug interaction alerts informed her of some medical knowledge that she hadn’t known previously. So, there are instances where various parts of an EMR software can provide better patient care, but is it dramatic enough difference to really improve the quality of care? I think that’s a hard argument to really make. At least with the current iteration of EMR software.

Other EMR Benefits
Quality of Care aside, I think the thing that studies like this (and their related headlines) miss is the other benefits of having an EMR system (see also my list of EMR benefits in my EMR Selection e-Book).

I can’t tell you how many times I’ve heard doctors talk about how they love the legibility and accessibility of patient charts in the EMR. No difficult to read handwriting (others or their own). No waiting for chart pulls. These are guaranteed benefits to having an EMR system. Sure, it’s hard to quantify them when it comes to dollar signs or improved quality of care. However, they’re a real tangible benefit to having an EMR. Not to mention that I still think there’s long term benefits to widespread adoption of EMR that we can’t even imagine yet.

I could go on about many of the other benefits. It’s just unfortunate that studies and those who report on these studies don’t take into account these other benefits of EMR software.

UPDATE: Over at HIStalk, Mr. H also points out that the study only focuses on a couple quality measures. So, it doesn’t actually say that EHR doesn’t improve quality of care, but instead it says that it doesn’t improve quality of care when it comes to the couple simple measures that the study used to measure it. There could be many other quality measures where EHR does improve the quality of care. We just don’t know.