Today I had an interesting conversation with MEDENT. It’s an EHR company that’s in only 8 states. I could actually write a whole post on just their approach to EMR software and the EMR market in general. They take a pretty unique approach to the market. They’ve exercised some restraint in their approach that I haven’t seen from many other EHR vendors. I’ll be interested to see how that plays out for them.

Their market approach aside, I was really intrigued by their approach to dealing with ICD-10. They actually described their approach to ICD-10 similar to how Google handled search. There’s all this information out there (or you could say all these new codes) and so they wanted to build a simple interface that would be able to easily and naturally filter the information (or codes in this case). A unique way of looking at the challenge of so many new ICD-10 codes.

However, that was just the base use case, but didn’t include what I consider applying AI (Artificial Intelligence) to really improve a user interface. The simple example they gave had to do with collecting data from their users about which things they typed and which codes they actually selected. This real time feedback is then added to the algorithm to improve how quickly you can get to the code you’re actually trying to find.

One interesting thing about incorporating this feedback from actual user experiences is that you could even create a customized personal experience in the EMR. In fact, that’s basically what Google has done with search with their search personalization (ie. when you’re logged in it knows your search history and details so it can personalize the search results for you). Although, when you start personalizing, you still have to make sure that the out of box experience is good. Plus, in healthcare you could do some great personalization around specialties as well that could be really beneficial.

I’d heard something similar from NextGen at the user group meeting applied to coding. The idea of tracking user behavior and incorporating those behaviors into the intelligence of the EMR is a fascinating subject to me. I just wonder how many other places in an EMR these same principles can apply.

I see these types of movements as part of the larger move to “Smart EMR Software.”

I saw this tweet and decided I couldn’t pass up posting it. When I read it, all I could think was, Yeah……right!! (yes, that last part is in the sarcasm font)

@NewIQ – David Whitaker
The next five years will be pivotal for EHR solutions. The cloud presents a real opportunity for the creation of a truly dynamic system.
Followed by…
I would not be surprised if the folks at Google or Facebook werent already working on a strategy. #EHR #cloud

I think the last thing Facebook is thinking about is anything to do with EHR. They might be interested in healthcare apps for “consumers” managing their health, but they couldn’t give a rip about EHR. They might even consider helping doctors connect with patients on Facebook (although, even that I think is unlikely), but not an EHR.

Google has probably thought of EHR back when Google Health launched. Obviously they chose to go with PHR and we see how that turned out. I don’t think Google could make a worse mistake than to try and create an EHR.

Yeah, Facebook or Google doing EHR…that would be surprising.

Let’s face it, I haven’t actually been nice to Google of late when it comes to healthcare (or maybe I have, just once). While I believe the criticisms are justified, I can see why some people might think I’m beating a dead horse, namely Google Health. But there are some unresolved questions in the area of privacy that Google really should answer.

Google’s ill-fated attempt at a PHR isn’t completely dead. The company won’t “retire” the online service until January, and will allow users to download their data through Jan. 1, 2013. Naturally, others have stepped up to try to fill the (tiny) void left by Google Health’s demise. To nobody’s surprise, Microsoft is helping the remarkably small number of Google Health users transition their accounts to HealthVault, Microsoft’s own overly hyped, underutilized PHR platform.

What concerns me is what will happen to data already on Google’s servers. Will records be archived? Will sensitive patient health data stay on Google’s servers in perpetuity? Nobody has said for sure.

Are records safe from Google’s data-mining juggernaut? Google has consistently said that it would not use health records for anything other than to steer traffic to its core search engine, but let’s face it, Google’s primary source of revenue is from algorithm-driven advertising.

But, you say, HIPAA protects patients from unauthorized uses of their data, right? Well, remember back to 2009, when the American Recovery and Reinvestment Act expressly made third-party data repositories, health information networks and, yes, personal health records, into HIPAA business associates, effectively holding them to the same rules as covered entities under HIPAA.

Wouldn’t you know, both Google and Microsoft came out and said they were not subject to this provision. No less an insider than former national health IT coordinator Dr. David Brailer, who was a part of the legislative negotiations, told me then that lawmakers had Google Health and HealthVault specifically in mind when they crafted the ARRA language. As far as I know, there haven’t been any reported data breaches involving either PHR platform, so there’s been no need to test whether ARRA actually does apply to them, but if I had my data on Google’s or Microsoft’s servers, I’d be concerned. I’d particularly want to know what Google plans on doing with the data it’s been holding once Google Health does shut down.

Perhaps it’s time for me to make some phone calls.

I’m not sure how many of you have followed the announcement of the Google 1+ button. If you haven’t seen them yet, you’ll start seeing them sprinkled all over the internet soon. I just added them to a couple of my sites including EMR and HIPAA. You can see it next to the Facebook button on the right side of each post. Feel free to click it if you’re reading a post that you like. It’s a simple action which can tell me a lot about whether people like the post or not.

Of course, I’ve been using social media indicators like this for a while. For example, I’ve known the number of people who tweeted out my various posts on Twitter. I often can see how many times an article gets published on Facebook. I always love to get feedback like this that tells me that someone liked the article I created. However, often tweeting a link or sharing a link on Facebook is more than someone wants to do. The Google 1+ is an even simpler and more anonymous way of telling a blogger or other website that you like what they’ve created. I’m interested to see how many people are willing to take the simple step of clicking the Google plus 1 button when they like a post.

However, beyond the benefit to a blogger of knowing which content its readers like, Google is no doubt going to use this information as well to create more targeted search results (and likely ads as well). Some people bristle at the idea that Google would have this information. However, I don’t have any problem with it. In fact, I like that Google will be able to provide me a better service. For example, if I search for EMR on Google, they should know I want to know about electronic medical record sites and not the EMR paintball one. I think data like the plus 1 could help Google to improve that experience for me. That’s a good thing.

I’ve been really interested in these social media indicators and the influence that someone can have online. For example, just because someone has a lot of followers, does that make them an authority? What if you find some health information online? How do you know the quality of that information? What if you’re searching for EMR software? How do you evaluate the quality of the information that’s being provided? What about any biases that information might have? Can social indicators help you to improve your understanding of the quality of the information?

I’m not sure the answers to many of these questions, but I do think there’s power in a crowd of people expressing their opinions on a subject. Even something as simple as clicking on a Google plus one benefit. Will it cure Cancer? No. However, it can still have a profound impact on the way we discover information and how we help others understand the quality of that information.

Yet again, someone needs to educate the general public about healthcare in general and health IT in particular.

HealthLeaders last week asked the question, “Does Decision Support Make Docs Look Dumb?” The story, apparently based on a 2007 study (not 2008, as HealthLeaders reported) in the journal Medical Decision Making, says: “Most clinicians would agree that evidence-based decision support tools have the potential to improve clinical quality. But patients’ perception of the tools—and the physicians who use them—might be yet another barrier to their adoption. The problem is twofold: Some patients are skeptical of docs who need a computer to help them make a diagnosis. And some physicians don’t want to be seen as being too reliant on technology.”

We’ve long known that physicians have resisted clinical decision support, for a variety of reasons. They trust their professional judgment. When they only have a few minutes with each patient, they believe it simply takes too long to look up information that might help reach a more accurate diagnosis or devise a better care plan. The technology simply isn’t up to snuff. Or there isn’t enough electronic data available on each patient for CDS to have a positive effect.

But to read the conclusion of that Medical Decision Making study is to see an entirely different excuse for shunning clinical decision support: “Patients may surmise that a physician who uses a [decision support system] is not as capable as a physician who makes the diagnosis with no assistance from a DSS.”

HealthLeaders interviews other clinicians and researchers who have found similar sentiments. “Patients object when they ask their doctor a question and then she or he immediately types in the question into their laptop and then reads back the answer. It gives patients the feeling that they just paid a $25 copay to have someone Google something for them,” Illinois State University information systems professor James Wolf tells the publication.

“Physicians are reluctant to adopt computer-based diagnostic decision aids, in part due to the fear of losing the respect of patients and colleagues,” Wolf adds.

If this is true, it represents failures on many levels. IT systems designers haven’t made their technology easy to use. Physicians and healthcare entities haven’t done a good job educating patients and journalists like myself have truly failed the public by continuing to feed them false expectations about healthcare.

First off, Wolf’s statement that patients feel like they wasted only a $25 copay perpetuates the myth that a physician office visit only costs $25. If patients think they may have wasted $25, how do you think insurance companies and employers must feel that another $150 of their money went out the window?

The part about losing respect is perhaps more troubling. Physicians need to put their fragile egos away and do whatever they need to do to provide better care. The status quo just isn’t cutting it.

I’ve had the distinct honor of interviewing Dr. Larry Weed on several occasions. Weed, the octogenarian inventor of the problem-oriented medical record and the SOAP note, has been calling for CDS and other IT for more than half a century. Yes, more than half a century. He’s been actively working on such technology since the early 1970s. In a 2009 interview with the Permanente Journal, Weed said:

Computer technology maximized access to voluminous data and knowledge, thereby exposing the limited information processing capacity of the human mind. Scientists cope with this limitation by controlling the research environment, defining the variables involved, and limiting the scope of their investigations. Practicing physicians do not have that luxury. The time constraints of practice and the enormous scope of information implicated by multiple problems in unique patients make it impossible for the human mind to function with scientific rigor. Physicians inevitably resort to dangerous cognitive shortcuts.

I realized that medicine must transition from an era where knowledge and information processing capacity resides inside a physician’s head to a new day where information technology would provide knowledge and the processing capacity to apply it to detailed patient data. The physicians’ unaided minds are incapable of recalling all the necessary knowledge from the literature and processing it with data from the unique patient. An epidemic of errors and waste is occurring as we persist in trying to do the impossible. Changing this requires that we recognize the crucial distinction between electronic access to information and electronic processing of information. This requires a rational standard of data organization in medical records. Yet, these points are still not recognized in most current discussions of health information technology.

As a result, I have been involved for the last 60 years in trying to design and develop a medical care system in which patients are no longer dependent on the limited, personal knowledge their caregivers happen to possess. The medical care system must resemble the transportation system, where consumers use knowledge captured in maps, road signs, computerized navigation devices, and the like at the time of need. Patients, like travelers, will be expected from childhood on to develop the necessary skills to navigate the system.

At all times, patients should be supported by caregivers who are highly trained in the necessary hands-on skills, like removing the appendix or listening to heart sounds, just as in the travel system there are pilots, mechanics, air-traffic controllers, and others who perform functions that travelers cannot perform.

Yet, few outside of academic medicine have ever heard of Weed and his pioneering work. Instead, we rely on shoddy reporting and sound bites designed to score political points to shape our opinions. Why do you think the debate around “healthcare reform” focused so much on insurance coverage rather than actual care? And why do you think patients still believe office visits and prescriptions really cost just $10 or $20 or $30? And why do so many people still expect their physicians to know everything?

We must do better.

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.

If you’ve been reading this blog for a little while, you might have noticed that I’m really struggling with whether I should use the term EMR or EHR. You can read about the difference between EMR and EHR on the wiki.

The problem I have is that for all practical purposes, EMR and EHR are being used synonymously. Yes, if we get to the nitty gritty there is a difference. However, if a doctor says they use an EMR or EHR in their office they’d mean the exact same thing. If I say I’m helping someone select an EMR or EHR in their office it would mean the same thing.

Basically, every EMR software could be called an EHR software. It’s really just branding. My problem is that I prefer the term EMR. It’s what I first used (thus the name of the website) and it’s what I used exclusively on this website for a couple years.

Now it’s en vogue to use the term EHR. I’m not very fond of the term EHR, but I almost feel like I have to use it since it’s the term people are starting to use more and more.

What kills me even more is that I want to be at the top of Google for EHR and EMR. However, Google doesn’t have common sense to realize that they’re essentially the same thing and should be ranked in similar ways. So, I walk this balance of using both terms and mastering neither of them on Google.

Since I’m on Google, I also want to openly tell Google to stop messing around with my Google Rank for the term EMR. Google keeps bouncing this website from the first page to the second page. Obviously the first page sends a lot more traffic this way and so you can imagine which I prefer. More importantly, Google should realize that this website is easily in the top 10 websites talking about EMR. If someone can show me 10 websites about EMR that are better than mine, then I’ll take it back. Until then, Google please place EMR and HIPAA permanently on the first page of results for the term EMR. Thanks!