There’s been an interesting situation going on between a couple EHR vendors. I first saw this when I got the press release that meridianEMR filed a lawsuit against UroChart. The lawsuit claims that UroChart obtained access to meridianEMR’s data.(Note: See this comment from IT Director of meridianEMR that discusses more details of what happened and how no data was breached.)

Lawsuits aside, meridianEMR is trying to capitalize on the situation by talking about their EMR security monitoring system was what notified them of the breach attack by UroChart. They call it their Advanced Monitoring System (AMS) and say it responds immediately to any breaches attacks and protects patient records.

I’m not sure if it’s a smart move to use a breach of their system as a way to promote their ability to protect patient records. I guess they can argue that their monitoring service was what protected their patient records. However, the lawsuit is claiming that patient records were at risk. I don’t think that’s something any EMR vendor wants tied to their name, is it?

Marketing strategy aside, this security monitoring service is interesting and I can’t say I’ve really seen something like it in any other EMR system. Sure, they all have some sort of audit tracking and trail. However, I think most EMR vendor’s strategy is not detection, but prevention. They harden their systems using the best techniques, but don’t do much to try and detect breaches. Should that be changed?

One problem with breaches is that good hackers know how to even avoid the detection part. I still remember when my friend showed me how he had hacked into a server and you could see him logged in. Then, he ran a script and you couldn’t see him anymore. I guess if you compare it to the physical world, it’s like having a camera watching the front door, but no camera on the back door. However, in the digital world there are lots of different doors, including those we don’t know about.

Some might argue that ignorance is bliss in this instance. Sure, no EMR vendor is going to admit that in public. Neither is a doctor. However, the regulations have made it pretty harsh when you know that there’s been a breach of your system. You basically have to make it known to all the world. However, if you don’t know that your EMR system has been compromised, then you have no such requirements.

I’m sure some people won’t like me saying this, but be sure that many doctors and EMR vendors have thought about this. I’m sure there were parallels in the paper world too. So, let’s not act like this is really that new. Although, certainly technology has made it possible to have much larger breaches.

One thing worth noting is that I haven’t seen a group of healthcare hackers forming. There’s no underground group of people that I’ve heard of that are trying to hack and get access to healthcare data. Financial data is much easier to monetize for a hacker than healthcare data. That’s not to say that healthcare data isn’t valuable and can’t have consequences if it’s put in the wrong hands. However, most hackers do it for the Lulz, for financial gain, or vengeance. Things could certainly change, but I haven’t seen healthcare as a prime target for hackers. I’d love to see if you have evidence that says otherwise.

If you evaluate the list of breaches that are published by HHS, this seems to agree with my above evaluation. Almost every single breach was just due to something being lost, a physical device being stolen (which you can almost guarantee they wanted the laptop and not the healthcare data which they probably didn’t even know was on the laptop), or inappropriate use by someone on a system already.

It will be interesting to see how these EMR security monitoring systems evolve. Plus, will we see more need for these type of protections and monitoring of EMR systems?

Many of you might remember my recent post about EMR Performance Issues (ie. EMR Slowness). Turns out, the post had a pretty big impact on some readers of the site. In fact, it sounds like it was partially therapeutic for some to realize that they’re not alone.

I asked permission to share one of the responses with you so you could get some more first hand perspective on the issue of EMR slowness. I share it in the hopes that others can be aware and avoid it. Plus, I hope the EHR vendors that read this will take it to heart and be fanatically focused on EMR speed and customer support.

I’ve removed the name of the writer and the names of the vendors. Plus, realize that it was written originally in an email communication and not necessarily to be published.

OMG…you hit the nail on the head with this post. Our EMR is so slow. It often takes minutes between pages. My clinical and front office staffs so frustrated. We have had nothing but finger pointing going on ever since.

Part of the issue is the interface between our practice management system VENDOR A and our EMR VENDOR B It takes a minimum of 3-4 minutes for data entered into VENDOR A to roll into VENDOR B. My front office staff has taken to entering the data twice, once in each program in order to get our patients registered timely. When you see 80-100 patients in a day, a few minutes makes all the difference.

Additionally, certain criteria does not roll over, namely email addresses. This makes it impossible for us to send out patient visit summaries thus we are unable to meet meaningful use for that criteria. Referring physician is another part that does not roll over.

The most frustrating part is that no one will take any responsibility for the issue much less work on fixing it. These two vendors spend all day playing the blame game. Fortunately for our practice, we have a wonderful IT company that we work with. Our IT specialist has spend countless hours trying to mediate between these two vendors. Most times he just fixes what he can but we are paying for his services in addition to the tech support agreement with VENDOR A and VENDOR B.

A perfect example happened this week when the EMR went down in one of our exam rooms.. First we spend at least 10-20 minutes on hold waiting for a VENDOR B tech to pick up the call. In this particular case, they worked remotely for at least 4 hours on this one computer only to tell us they could not fix it.

I called my IT guy and he fixed it within 10 minutes. My staff spends countless hours on the phone most days trying to keep the system up and running. We are in the process of replacing all our PCs and I recently upgraded our Internet to a 10×10 fiber service however we still are not seeing any difference in speed.

It is at least comforting to know we are not alone. I plan to hang up your post for all my staff to see. It may not make our system work faster but hopefully it will give them some comfort knowing they are not alone.

Thanks for all the great information.

I’m not sure all the details of why this is the case (but I’m sure some will tell me why in the comments), but doctors are some of the most independent thinkers that I know. I’m not saying whether this is a good or a bad thing. It’s just an observation based on thousands of interactions with doctors from all specialties. This independence is shown in a plethora of areas from charting to treating to diagnosing to the business of medicine.

Turns out, this independence is part of why I’ve heard doctors say hundreds of times that they basically want their own EHR and not a mainstream one. Doctors want an EHR that fits their unique practice style. Thus they have an expectation that whatever EHR they choose should understand that each doctor is different and naturally adapt to each unique doctors need. Ok, that’s a pretty broad generalization and no one would ever vocalize it that way, but it’s an undercurrent that I’ve seen time and time again.

I believe this is an important characteristic of the EHR market that must be considered. If you don’t accept the broad theory of doctor independence in practice style and approach, then most of you will appreciate that doctors from various specialties have unique needs. The easy to understand examples are Pediatricians and OB/GYNs. Everyone can quite readily see that tracking child growth and pregnancy require different charting and documentation requirements. I believe each specialty could describe similar requirements that are unique to that specialty.

This doctor and specialty independence is why I’ve long argued against what everyone loves to call mass EHR vendor consolidation. Certainly we can all agree that we have too many EHR vendors right now. However, I’ve read many many people argue that there’s only going to be 3-5 EHR vendors left standing after the mass EHR consolidation (or EHR vendor failure). I just don’t believe that’s the case. If we get down to 100 EHR companies, I’ll be impressed.

There are two things that might partially affect my EHR consolidation prediction.

First, I won’t be surprised if some really smart company comes along and scoops up each of the best of breed EHR companies for various specialties. However, instead of sunsetting the acquired EHR software, they continue to offer that same EHR software to a specific specialty. Then, they do this over and over again across all the specialties. So, the larger company would own a pediactric EHR, an OB/GYN EHR, a Family Practice EHR, a Cardiology EHR, a Orthopedic EHR, an Oncology EHR, etc. You get the idea. Instead of getting benefits from software development consolidation, they get the benefits in other areas of their business. It would be really fun to run a company like this.

The other healthcare trends that could have a serious impact on this is the ACO movement and hospitals buying up clinics. I’m still not sure how those two trends are going to play out. However, this type of consolidation of healthcare entities could impact whether a specialty specific EHR is a viable option. Clinics that are bought by a hospital or become part of an ACO lose some of their independence. At least their independence in selecting an EHR software.

Are there things I’m missing? Any other trends that are happening that will change the EHR consolidation landscape?

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

June 19, 2011 10:27 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 7:01 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.

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.

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.