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.

I’ve regularly talked about my belief that there isn’t just one major EMR market. Instead, I firmly believe that there are a number of EMR markets that are divided by clinic size, medical specialty, and possibly even location. In fact, there’s likely even other factors. There are just far too many EHR companies for this to not be the case.

I think this was also well illustrated in this blog post on Kevin MD about the “Perfect EMR Traits.” Here’s the perfect EMR trait #1:

Perfect EMR Trait #1: The ideal medical record would be tailored to the specific needs of a clinician, only exposing them to portions of the record which are relevant to their work.

Knowledge within healthcare is rapidly changing. Possibly more so than another other industry. Techniques which were considered state-of-the-art, can change in a matter of weeks. The electronic medical record has the potential to be the tool which disseminates those changes down to the clinician, through point-of-care decision support. EMR software should facilitate the clinician decision making, rather than requiring clinicians to keep track of the latest and greatest. This individualistic attitude creates discrepancies in care, which inherently leads to imprecise care.

While it is certainly technically feasible for an EMR vendor to be able to create software that satisfies Perfect EMR Trait #1, it’s just not practically feasible for an EMR vendor to satisfy every clinic size, medical specialty, and in many cases locale. This means that we’re going to see a wide variety of EMR software that satisfies the various EMR market needs.

With this as a preface, consolidation of EMR companies is going to become a very very real thing. However, I’d caution EMR companies that choose to just directly sunset an EMR software acquisition. In some cases, this is a reasonable solution based upon the EMR company’s existing EMR software. Plus, in many cases EMR vendors will be acquiring the EMR market share for their existing EMR software. I’m sure we’ll see more of this.

My recommendation for EMR vendors acquiring EMR software, is to be more selective in the types of EMR software that you acquire. It’s definitely worth considering the idea of sustaining the EMR software development of multiple EMR products. Is it really that hard to see a large EMR company that has an ED EMR software, a General Medicine EMR software, an OB/GYN EMR software, a Pediatric EMR software, etc etc etc.

An EMR vendor making a decision to act in this manner will require them to change how they look at EMR acquisitions. The EMR acquisition targets will dramatically change. Instead of looking for failing EMR companies where they can cheaply buy more EMR market share, EMR companies with this approach should be focusing on a quality EMR software that hasn’t yet achieved the EMR market share that they deserve.

The cool part about the strategy of maintaining multiple EMR software instead of the strategy of sunsetting one or the other is that you purchase a bunch of happy EMR users instead of alienating a whole mass of EMR users that’s software is no longer supported. Of course, this will require proper communication of your goals and objectives so that current EMR users see the benefit of the acquisition and aren’t left wondering what the acquisition means to them. I’m not just talking about standard PR spin. I mean real tangible communication and interaction which demonstrates your plans for the acquired EMR going forward.

An EMR company with this method of EMR software acquisition, also needs a different set of skills. After sunsetting an acquired EMR, you need to have a strong set of integration and transition services to make the change to your EMR as smooth as possible. You also require a unique sales force that can sell the transition to your EMR over a transition to an altogether new EMR software. None of these services are needed if you continue to maintain the acquired EMR. Instead, your company must focus on other redundant services like marketing that could be leveraged across companies.

Of course, this isn’t an easy task to do well. Acquisitions rarely are an easy process. However, I think this is a lesson that was recently learned by Google as well. There’s value after an acquisition to keep autonomous business units. In fact, doing so opens up a whole new set of acquisition targets in a less competitive environment.

If I were a board member at an EMR company, this is the type of stuff I’d be considering. Certainly not every EMR vendor is 1. in a position to do these things and 2. has the culture to make it happen. However, I predict that the EMR company of the future will be a conglomerate of multiple specialty specific EMR software and not just a one size fits all atrocity.

It has become more and more apparent that the way an EMR vendor implements the meaningful use requirements is going to be critically important to a doctor’s successful adoption of the meaningful use criteria which is of course essential to get the $44,000 in EMR stimulus money.

I think it’s easy for doctors and practice managers that aren’t as familiar with the various EMR software and with the details of the EMR stimulus to get confused. On face, it seems that the effort to get the EMR stimulus money shouldn’t be affected by which EMR software you choose as long as it is an ONC-ATCB certified EMR. However, this is just categorically WRONG!

The EHR certification is meant to tell you that it CAN meet the meaningful use guidelines. It doesn’t tell you how easily it is to meet the meaningful use guidelines. It doesn’t tell you how well they integrated the meaningful use guidelines into your regular workflow. It doesn’t tell you how well it lets you delegate the meaningful use tasks to other staff members so you can optimize the doctors time. So, yes, EHR certification should mean it’s possible to show meaningful use. EHR certification does not make any claims to how effective that EHR software will actually accomplish the task.

Here’s a simple analogy:
If I wanted to dig a hole for a footing on a house, I could probably use a spoon to dig the hole. It would take forever to actually dig the hole, but a spoon could work. It would suck to use a spoon to dig the hole and quite honestly I’d probably give up before I finished, but with enough blood sweat and tears I could get the hole dug.

Of course, if I had a shovel, digging the hole would be much easier. I could get it done with just a bit of hard work. It would obviously go a lot faster than a spoon. Now, if I had a backhoe, digging the hole would basically be academic. Achieving the goal would be simple to accomplish, because the tool was designed perfectly to achieve it.

It’s worth asking yourself whether the EMR you use or the EMR you choose is a golden spoon or a powerful backhoe when it comes to achieving meaningful use. Maybe both can achieve the goal of meaningful use, but is it just made to look nice and shiny or was it really designed to make achieving meaningful use as painless as possible?

Thanks to Randall Oates from SOAPware and Evan Steele from SRSsoft for inspiring this post.

I was talking with Randall recently about SOAPware’s approach to EHR certification and meaningful use. He told me that SOAPware could have thrown something together quickly and been easily certified against the EHR certification criteria when it first opened. However, he didn’t like that approach. Instead he wanted SOAPware to take its time and make sure that the criteria were implemented in a usable and useful way.

Evan just posted a blog post about not all meaningful use EMR being equal. Here’s one portion of what he said that prompted this post:

Demonstrating meaningful use will still demand additional work, and certified—or to-be-certified—EMRs are not alike in how they facilitate doing this. It is critical for physicians to understand and evaluate the differences among EMRs in terms of how they deliver meaningful use capability and the impact on the time it takes to meet the requirements with each.

Evan also offers a few suggestions on things you might ask your EMR vendor:
*How easy is it to enter the required data? (This is particularly important as requirements become more demanding in future stages of the program.)
*What changes will you have to make to the way you see patients?
*How will you document the care you provide?
*Does the system effectively allow delegation of tasks to staff members to minimize the time physicians must spend doing data entry?
*Does the vendor’s software platform enable keeping up with evolving requirements?

There you go! Now you have a list of questions you can ask SRSsoft (and other EMR vendors) when you’re evaluating them.

I’d love to hear other ways people are evaluating an EMR vendor’s implementation of meaningful use. Not to mention ways that EMR vendor’s have implemented meaningful use that differentiates themselves from other EMR vendors.

The following is a guest blog post by Dr. Michael West. I recently met Dr. West and was really impressed with his approach to EHR. After reading a few of his comments on the site, I asked if he was interested in doing some guest blog posts. This is the first of what I hope will be many more blog posts by Dr. West.

Dr. West is an endocrinologist in private practice in Washington, DC. He completed fellowship training in Endocrinology and Metabolism at the Johns Hopkins University School of Medicine. Dr. West opened The Washington Endocrine Clinic, PLLC, as a solo practice in 2009.

When, I was in residency at a large health system in Pennsylvania, several of the residents and interns got into the habit of templating hospital notes on their home computers the night before they would go in to see patients who were chronic players with multiple medical problems who would often stay for long times in the hospital. I’ll openly admit that I was one of the many who bought into the perceived need to make things more efficient in order to get out of the hospital sooner and have a better home life. The concept was simple: design a pre-templated note for each chronic patient, detailing the plans (which would rarely, if ever, change), and then save it and mass produce at will. Of course, this did not go over well with our purist administration who were in charge of ensuring the highest quality, authentic notes for each patient on each day. In their correctness, they noted that sometimes these notes would be put into patient charts without those small changes that would, in fact, take place from day to day, thus resulting in erroneous documentation.

Now, years later, in the world of EHRs, there seems to be a push-back against the “cut and paste” concept. I know this is out there for two reasons: one, because I have read a blog or two citing it, and two, because I have enjoyed doing it myself. In the cut-and-paste world of computerized documentation, it’s addictively efficient. Gutenberg, the inventor of the printing press which allowed mass production of books and changed the world, would be proud. The responsibility for using such powerful efficiency does fall to the individual health provider to carefully review, edit, add and subtract documentation to ensure current accuracy. However, if done correctly, it allows careful preservation of a summary of what came before.

For this, I have some personal recommendations. First, actually DO the editing, don’t just cut, paste, and sign. Second, go back and refine the previous note for word choice and economy. Otherwise, you will create endless run-on documentation that is unprofessional in appearance and a burden for your colleagues to wade through later. From a billing perspective, it facilitates and supports that you have actually reviewed the patient’s previous history rather than just asking them what’s going on today. I find that cutting and pasting the old plan prompts me to consider everything I was trying to accomplish after the last visit and promotes holding the patient accountable for getting all of their previous orders accomplished. If something was not followed up on by the patient despite my recommendation, then this definitely gets documented in the current note. And then, of course, I ask them to “try, try again.”

I find nothing inherently wrong in this process and my patients get the benefits of an accurate portrayal and review of their conditions with appropriate follow up evaluation and managent. So cut, paste, edit, and save your evenings for yourself, rather than dictating entirely new notes that regurgitate the same old information. Work smart, while still working hard.

Honestly, this is one of my favorite discussions to have about an EMR system. The only hard part is that it’s an endless debate with no clear resolution. However, the choices that an EMR vendor makes in regards to their cookie cutter vs. customizable approach is really important.

For those who aren’t as familiar with the issue, the challenge lies mainly in out of the box utility vs. ongoing improvement.

The first part of that challenge is that most doctors think that when they spend their hard earned money on an EMR software, that it should be able to just work out of the box. I think many of the other software programs and other things we buy have created this culture of things just working. For example, it’s amazing how few things you have to do to setup a new computer when you buy it. The computer manufacturers have done a great job making it dead simple to get your computer and be using it shortly after pulling it out of the box.

Most people want this same type of thing to happen with an EMR. Sure, they realize that there will be some customization and entry of their clinic specific data. It’s understandable to have to create some users, add in your address and phone number and a few things like that. However, there’s this expectation that I should be able to just start using the system. Many are surprised when they start documenting their first patient to realize that there are no templates (or insert other EMR feature) available to them for that patient.

Of course, in the EMR vendors defense it’s a challenge to pre-load the information in a way that it just works out of the box. Certainly an EMR vendor could load it up with every template imaginable. However, then they’d hear the complaint that the pediatric doctor had no need for those GYN templates and what kind of silly EMR vendor would make that simple mistake. Of course the EMR vendor knows this fact, but how do you build a software that can take this into account. Much easier said than done.

Of course, some EMR vendors have approached these challenges by providing a real cookie cutter approach to EMR. The complaints then come that the EMR system isn’t customizable enough for the doctor. Of course, these are the same people that would have complained about all the customization they would have had to do if they were just given a really bare bones EMR software install.

The reality is that every practice is different and so it’s a major challenge for EMR vendors to balance these two competing interests.

At its core, the EMR software needs to be as setup as possible right out of the box. However, it also needs to provide as much customization as possible so that when the out of the box features aren’t right for a particular practice it can be changed to fit their needs. It’s a funny little balancing act that has more basis in art than science. However, when done right it makes a huge difference.

What types of things do you do or have you seen to solve these challenges?

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.

In a recent discussion I had, someone brought up a really interesting question about module certification to me. Obviously, proving that you use a certified EHR is quite easy if you just use one EHR software that’s a complete certified EHR based on the ARRA guidelines. Then, you can fitfully say that you use a certified EHR.

Even this isn’t that confusing if you use one complete EHR software for everything, but say ePrescribing. Of course, the ePrescribing vendor would need to be certified for those modules, but you can easily show that both are certified EHR and you use all the modules.

The questions start coming in when you start to talk about module EHR certification when you just purchase parts of a software. Let’s say you purchase only part of a certified EHR software (ie. no ePrescribing and no Patient Portal). You don’t purchase those 2 modules since you already use other software to match those needs and their certified for those modules.

The problem with this scenario is how do we know that the main EHR software that you purchased has all of the certified EHR functions if you never purchased two major components? How do we know that the ePrescribing component actually also did some other part of the EHR certification that wasn’t part of the ePrescribing module certification?

Of course, you could easily argue that it doesn’t really matter because if you’re able to show meaningful use with what you bought, then does it matter if your combined EHR software with the other modules wouldn’t technically have passed an EHR certification? It absolutely doesn’t matter. In fact, that’s exactly why EHR certification is a shameful waste of money and time. If I can meet the meaningful use guidelines using a typewriter, then who cares if the typewriter is certified or not?

Moral of the Story (since this isn’t one of my clearest posts): This whole idea of modular certification is going to be messy.

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.

I was recently sent an Information Week article on the “Steady Bleed: State of HealthCare Data Breaches.” The article basically tries to list out all of the data breaches that are happening in healthcare and how healthcare companies aren’t doing what they need to do to protect patient data.

Now, I’ll be the first to acknowledge that more can always be done. I even agree that more can and needs to be done to protect patient information. However, I don’t agree with the article’s assertion that the use of an electronic health record (EHR) is the reason why health care providers are so poorly securing patient information.

Many of you might remember my post on EMR and EHR about HIPAA Breaches related to EMR. In that post, I discuss how it’s unfair for someone to automatically assume that if there was a breach, then it was the electronic medical record software’s fault. In the analysis I did in the above post, I found that most of the HHS list had nothing to do with EMR software. In fact, many of the HIPAA breaches were lost devices which contained lists of insurance information. EHR had nothing to do with that.

I’m not saying that breaches don’t happen with an EMR. They do. However, most of the examples given in the Information Week article could have happened just as easily in the paper world. It didn’t take an electronic health record for people to start looking up famous sports stars health information.

Maybe the real difference with an EHR is that now we can know and track who accesses each patient record. That just means that now we actually know about all the violations whereas with paper charts they’d just happen and we’d likely never know about it or have a way to prove that it happened. So, yes, the number of reported HIPAA breaches should be going up. We have more information to report on.

The good thing long term is that with an EHR we now have tracking mechanisms that allow us to hold someone accountable for their breaches of HIPAA. If this accountability is taken seriously, the number of breaches will go down. That’s a much better long term solution than the naive ignorance of not knowing about breaches in the paper chart world.

Sure not all EHR software is secure. They need to fix that and improve that. However, the numbers and reports I’ve seen don’t seem to indicate that breaching an EHR software’s security is the real problem. There are far easier ways to take patient data than trying to breach an EHR’s security system. Let’s focus on those other ways that people take patient data and punish it appropriately. That’s far more productive than saying that we’re rushing too quickly into an unsecured EHR world.

I knew that my previous post about the cost to update an EMR would bring out the people who like to back the SaaS EMR model versus those who like to back the Client Server EMR. As I’ve said before, it’s one of the most heated debates you can have in the EMR space.

I realized in the comments of that post why it’s such a heated topic. It’s because once an EMR software chooses to go down one path or the other, it’s nearly impossible to be able to switch paths. Why? Cause if you do choose to switch you basically have to just code a new application all over. Basically, the switching costs are enormous. So, only a few software companies (let alone EMR software companies) ever change from one to the other.

Considering the high switching costs, that basically means that an EMR vendor that is SaaS based has a strong vested interest in the benefits and upside of the SaaS model of software development. The same is true for Client Server EMR software and client server EMR companies looking at the benefits and upside of the client server model of software development.

This entrenching around a software development methodology (for which they can’t change) is what makes discussing each model so interesting. Each party dutifully makes the most of whichever software development methodology they’ve been given.

Of course, from the clinical perspective it’s sometimes hard to cut through all this discussion and get good information on the real pros and cons of each model.

In that vein, I’m looking for a couple EMR and HIPAA readers that would be interested in making the case for one or the other. All you’d need to do is create a guest blog post on the pros and cons of your preferred method. If needed, you’d also be welcome to do a response post to the other method’s post as well.

If this interests you, leave a comment or let me know on my Contact Us page. I think this could be really interesting.

On a different note, it looks like I’m going to be attending the AAFP conference in Denver next week. Is anyone else planning to be there? Anything I should know about the conference to get the most out of it?