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

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

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

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

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

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

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

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

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

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

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

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

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

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

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

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

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

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

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

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

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

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

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

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

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

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

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

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

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

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

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

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

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

EMRandHIPAA.com’s HIMSS11 coverage is sponsored by Practice Fusion, provider of the free, web-based Electronic Medical Records (EMR) system used by over 70,000 healthcare providers in the US.

My last post on EMR companies holding practice data for ransom was very popular and had some very interesting discussion in the comments. Honestly, every EMR vendor should be considering the impact of the choice to not liberate the data in the EMR.

No, I’m not talking about being loose with the data. HIPAA will come back to bite you if you do that. Plus, no doctor will want to use your system. What I’m talking about is making the data in the EMR available to the doctor. In fact, if your a doctor or practice manager reading this post, you should make this a requirement of the EMR vendor you select. If you already have an EMR vendor, you should work to have them incorporate this feature in their EMR ASAP.

Lest you think that I’m just being pro doctor and not considering the EMR vendor, let me provide you some business reasons why an EMR vendor would want to create a plan to make the data in their EMR available to their doctor in a liberated format.

As one EMR vendor put it:

Bottom line, its a good business practice to provide the data in an accessible manner to the client when and if he/she wishes to move on to another EHR.

Let me add the following:

If you don’t hold the EMR data ransom then you will have a better image in the community.

1. If someone wants to leave and you make it hard, word will travel that you held them ransom and others will be afraid to choose you because they know they’ll be locked in. We all know how tight the medical community is.

2. If you free the data, users will trust you more cause they know they can leave at any time. Plus, they see you’re doing what’s best for the customer. This narrow minded focus on the customer’s needs will certainly carry over into other areas of your application and lead to happy customers who can leave, but won’t have any reason to leave.

3. SaaS EHR vendors in particular should offer this service. One of doctors biggest complaints about SaaS EHR is their fear that their EMR data isn’t stored in their office. What easier way to allay this fear than to provide them a regular copy of their data?

Do NOT underestimate the power of your image with the customer. It leads to happy long term customers, but also leads to future customers. I saw a recent study (which I can’t find right now), but it was amazing to see the amount of influence that other colleagues EMR recommendations made on a doctor’s EMR selection decision. Providing doctors their EMR data which may lose you a few customers along the way, but it will retain and find more customers than you lose.

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.

A few months ago, the blogger over at Health Finch wrote blog post which analyzes 3 of the top health care IT companies and how they were started. It is very interesting to see the evolution of the large health care IT companies. Here’s the summary of the 3 companies Health Finch looked at:
Epic Systems – Started with Scheduling and Billing
Cerner – Started as a Laboratory Information System
McKesson – Started dong Rx Management

As a PS to the post, they point out Epocrates working on the same model with their Epocrates EMR. That is one of the most interesting things I’ve noted when attending the various EMR related conferences that I attend. There’s a whole variety of ways that EMR companies are approaching the market.

Another example of this trend is the Care360 EHR from Quest. Think about all the benefits that Quest has over many other providers. Sure, the most obvious one is that they have easy access to the lab data. You can be sure that an interface with Quest labs will be free (unlike most other EMR vendors). Although, certainly it also could be a challenge if you want your EMR to interface with another lab. That could be interesting.

However, Quest has a number of other advantages over a new EMR company. They have an entire sales force (which I think they prefer to call consultants) that already have existing relationships with thousands and thousands of doctors. Quest could literally only sell EMR software to their existing lab customer base and do fine. Of course, that’s probably not the best strategy, but that’s a powerful advantage over the other EMR companies.

There are a ton of other companies that we could talk about. Those entering ePrescribing first. Those transcription companies that are offering an EMR solution. I find it absolutely fascinating. So, if you know of others, I’d love to hear your EMR vendor’s story in the comments.

Suffice it to say that we’re in the middle of an all out war by EMR vendors. The good part is that it’s not likely to be a winner takes all affair, but there will be many many EMR vendors that will end up on the winning end.

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.

It’s the weekend and I have this cool new Twitter plugin, so I decided it would be fun to do a twitter roundup. I’ll post some of the tweets I find and add some short commentary. I’ll admit that I haven’t necessarily read all of the links, but the concepts I found interesting. As a side note, you can find me on @ehrandhit and @techguy (although this one has all sorts of tweets).

How will #EHRs change the legal landscape for docs? And with such legal uncertainty, is investing worth it? http://bit.ly/fNF2zy #HealthIT

November 23, 2010 12:15 pm via TweetDeckReplyRetweetFavorite

@HITExchange

Jenny Laurello

I’ve discussed the changing legal landscape in the EHR world. My personal feeling is that it’s a legal wash. There are likely more liabilities with EHR, but it also resolves some of the liabilities of a paper chart world. What do you think?

Move over, handsets! The future of #HealthIT is mobile and WiFi based voice units and smart phones w. VoIP capabilities http://bit.ly/eVMRFr

November 23, 2010 1:20 pm via TweetDeckReplyRetweetFavorite

@HITExchange

Jenny Laurello

Mobile in healthcare is going to be a common theme going forward. I also love VoIP in many situations, but I’m still waiting to see the real breakthrough that makes VoIP the only solution. We’ll see.

Just started a new electronic medical record project (emr). Anyone else working on this?

November 24, 2010 6:33 pm via EchofonReplyRetweetFavorite

@Blumin

Scott Blumin

I wonder how many responses he’s gotten. I think he’s in very good company as far as starting EMR projects. I’m just not sure how many are on Twitter and know of him. I figured I’d let others find him:-)

glaucoma calculator… delimited to import into an electronic medical record or to automatically reserve date http://bit.ly/goIZOM

November 24, 2010 11:35 am via itweetliveReplyRetweetFavorite

@cebu_doctors

cebu doctors

I know nothing about this glaucoma calculator or this person on Twitter. However, I think this is an example of the hundreds and even thousands of very specific niche applications that are going to hit the healthcare IT market.

Very interesting new startup ElationEMR innovative web-based electronic medical record for physician practices.#elationemr #startups

November 23, 2010 7:11 pm via webReplyRetweetFavorite

@christinesario

ChristineSarioValdes

Another EMR vendor to add to the 300+ EMR vendors. I wonder how often a new tweet is sent for a new EMR vendor. Anyone know anything about ElationEMR?

Speaking of new EMR vendors…

@NEJM #Electronic #medical #record keeping is an underutilized opportunity that has shown strong interest from the #investing community.

November 28, 2010 3:49 pm via webReplyRetweetFavorite

@DaltonCapital

Dalton Capital

I’ve seen some financial statements for the EMR business model. There’s certainly a great investment opportunity available to those who are able to get a reasonable amount of EMR sales.

One of the biggest complaints surrounding the implementation of an EMR is the way the EMR software handles the documentation method. Beyond just the learning curve, there are plenty of EMR software that have a terrible user experience.

While I don’t want to totally let EMR vendors off the hook, I do think it’s worth noting that EMR vendors aren’t completely to blame for the unwieldy interfaces. I believe one of the biggest reasons that the EMR documentation interfaces are so terrible is thanks to the crazy insurance billing and documentation requirements.

Seriously, it’s a total mess. Everyone that’s involved with insurance billing in healthcare knows what I’m talking about. Trying to code an application that’s easy to use, works well for the doctors and still handles all the insurance billing and documentation requirements is a serious challenge and so it’s not surprising why so many EMR software fails to deliver a great user experience.

That’s not to say that all EMR software have terrible user experiences. Although, let’s be honest that they’re taking on a nearly impossible task. I guess I compare the insurance documentation and billing requirements to cleaning a toilet. Nobody really likes to do either. Yet, they’re absolutely necessary jobs. Certainly there are some tools that can make cleaning a toilet easier (gloves, wands, cleaning solutions, etc). However, it’s still a task that isn’t fun to do no matter how you slice it (unless you pay someone else to do it, but the pain of the expense is still there). The billing and documentation parts of an EMR software are trying to do the same thing: make a task that no one likes easier. Unfortunately, using an EMR isn’t going to change a task that no one likes into something fun.

I hope that EMR vendors don’t use this as an excuse to not focus on creating usable software. It’s NOT! However, I think it’s important to consider the true impact of the EMR. Is it really the EMR software that is so bad or did you hate these parts of practicing medicine before having an EMR as well?

If you find that it’s the EMR software that’s so bad, then hopefully you were smart in the contract you signed with your EMR vendor (see the EMR contract section of my Free EMR Selection e-Book). You won’t be the first or the last practice to switch EMR vendors.

Of course, if the complicated insurance billing and documentation is the problem. Maybe Obamacare’s single payer insurance plan will help to solve that issue. At least there would only be one organization to deal with.