In a number of my online conversations we’ve been having really in depth discussions about the idea of whether it’s better for a hospital HIS system is better as an All-In-One system or whether Best of Breed healthcare IT systems are better. Much of this discussion has been sparked from posts done on my Hospital EMR and EHR blog. So, if you’re in the hospital space and are not following that site, you should. You can even sign up for the Hospital EMR and EHR list if you’d like. Anne Zieger writes most of the content there and she doesn’t mince words.

In all of these discussions, something became really clear to me:

The best reason to use Best of Breed healthcare IT systems is for usability.

The best reason to use an All-in-One system is for interoperability.

Some people may see this as too simplistic, but I loved a quote I read recently that said you don’t truly understand something until you can describe it in a simple form. I actually heard Bill Belichick do this talking about what he looks for in receivers for his Football team (Anyone excited for Super Bowl Sunday?). He said he likes a receiver that can Get Open and Catches the Ball. Seems far too simplistic, but it’s so simplistic it’s genius.

I think the same could be said for evaluating hospital IT systems:

The thing I like most in a healthcare IT system is one that’s Usable and Integrates Well.

As is often common at the end of the year, a lot of companies have started putting together their “Top 10″ (or some similar number) lists for 2011. In fact, some of them have posted these lists a little bit earlier than usual. This week as people are often off work or on vacation, I thought it might be fun to take one list each day and comment on the various items people have on their lists.

The first list comes from Booz Allen Hamilton and is Booz Allen’s Top 9 ways IT is Transforming healthcare. Here’s their list of 9 items with my own commentary after each item.

Reduces medical errors. I prefer to say that Health IT has the potential to reduce medical errors. I also think long term that health IT and EMR will reduce medical errors. However, in the interim it will depend on how people actually use these systems. Used improperly, it can actually cause more medical errors. There have been studies out that show both an improvement in medical errors and an increase in medical errors.

My take on this is that EMR and health IT improves certain areas and hurts other areas. However, as we improve these systems and use of these systems, then over all medical errors will go down. However, remember that even once these systems are perfect they’re still going to be run be imperfect humans that are just trying to do their best (at least most of them). Even so, long term health IT and EMR software will be something that will benefit healthcare as far as reducing medical errors.

Improves collaboration throughout the health care system. I’m a little torn as we consider whether health IT improves collaboration. The biggest argument you can make for this is that it’s really hard to be truly interoperable in really meaningful and quick ways without technology. Sure, we’ve been able to fax over medical records which no one would doubt has improved health care. However, those faxes often get their too late since they take time to process. Technology will be the solution to solving this problem.

The real conundrum here is the value that could be achieved by sending specific data. A fax is basically a mass of data which can’t be processed by a computer in any meaningful way. How much nicer would it be to have an allergy passed from one system to another. No request for information was made. No waiting for a response from a medical records department. Just a notification on the new doctor’s screen that the patient is allergic to something or is taking a drug that might have contraindications with the one the new doctor is trying to prescribe. This sort of seamless exchange of data is where we should and could be if it weren’t for data silos and economics.

Ensures better patient-care transition. This year there was a whole conference dedicated to this idea. No doubt there is merit in what’s possible. The problems here are similar to those mentioned above in the care collaboration section. Sadly, the technology is there and ready to be deployed. It’s connecting the bureaucratic and financial dots to make it a reality.

Enables faster, better emergency care. I’m not sure why, but the emergency room gets lots of interesting technology that no one else in healthcare gets. I imagine it’s because emergency rooms can easily argue that they’re a little bit “different” from the rest of the hospital and so they are able to often embark on neat technology projects without the weight of the whole hospital around their neck.

One of the technologies I love in emergency care is connecting the emergency rooms with the ambulances. There are so many cool options out there and with 3G finally coming into its own, connectivity isn’t nearly the problem that it use to be. Plus, there are even consumer apps like MyCrisisRecords that are trying to make an in road in emergency care. I’d like to see broader adoption of these apps in emergency rooms, but you can see the promise.

Empowers patients and their families to participate in care decisions. Many might argue that with Google Health Failing and Microsoft HealthVault not making much noise, that the idea of empowering patients might not be as strong. Turns out that the reality is quite the opposite.

Patients and families are participating more and more in care decisions. There just isn’t one dominant market leader that facilitates this interaction. Patients and families are using an amalgamation of technologies and the all powerful Google to participate in their care. This trend will continue to become more popular. We’ll see if any company can really capture the energy of this movement in a way that they become the dominant market leader or whether it will remain a really fluid environment.

Makes care more convenient for patients. I believe we’re starting to see the inklings of this happening. At the core of this for me is patient online scheduling and patient online visits. Maybe it could more simply be identified as: patient communication with providers.

I don’t think 2011 has been the watershed year for convenient access to doctors by patients. However, we’re starting to see inroads made which will open up the doors for the flood of patients that want to have these types of interactions.

Helps care for the warfighter. This is an area where I also don’t have a lot of experience. Although, I do remember one visit with someone from the Army at a conference. In that short chat we had, he talked about all the issues the Army had been dealing with for decades: patient record standards, patient identifiers, multiple locations (see Iraq and Afghanistan), multiple systems, etc. The problem he identified was that much of it was classified and so it couldn’t be shared. I hope health IT does help our warriors. It should!

Enhances ability to respond to public health emergencies and disasters. I’ve been to quite a few presentations where people have talked about the benefits and challenges associated with electronic medical records and natural disasters. They’ve always been really insightful since they almost always have 5-6 “I hadn’t thought of that” moments that make you realize that we’re not as secure and prepared for disasters as we think we are.

It is worth noting that moving 100,000 patient records electronically to an off site location is much easier in the electronic world than it is in paper. With paper charts we can’t even really discuss the idea of remote access to the record in the case of a natural disaster.

Possibly even more interesting is the idea of EMR and health IT supporting public health emergencies. We’re just beginning to aggregate health data from EMR software that could help us identify and mitigate the impact of a public health emergency. Certainly none of these systems are going to be perfect. Many of these systems are going to miss things we wish they’d seen. However, there’s real potential benefit in them helping is identify public health emergencies before they become catastrophes.

Enables discovery in new medical breakthroughs and provides a platform for innovation. Most of the medical breakthroughs we’ve experienced in the last 20 years would likely have been impossible without technology. Plus, I don’t think we’ve even started to tap the power that could be available from the mounds of healthcare data that we have available to us. This is why I’m so excited about the Health.Data.Gov health data sharing program that Priya wrote about on EMR and EHR. There’s so many more medical discoveries that will be facilitated by healthcare data.

There you have it. What do you think of these 9 items? Are there other things that you see happening that will impact the above items? Are there trends that we should be watching in health IT in 2012?

Be sure to read the rest of my Health IT Top 10 as they’re posted.

I’ve been really intrigued lately by the changing media landscape. Things like Blogs and Twitter are providing opportunities for basically anyone to be able to share a message with the world. Certainly, many of the blogs don’t get read and a tweet on Twitter falls off people’s radar very quickly. However, some of the better or more interesting ones rise to the top and provide an interesting and sometimes dissenting voice to the conversation. Personally, I think this type of open discussion around topics is valuable and beneficial as long as people maintain a certain level of respect and decency.

My question to you then, is what would you say to a Healthcare IT audience?

As I considered on this difficult question myself, I decided the message that I would want to deliver: You can resist all you want, but the future of healthcare will require IT.

Pretty much every day, someone comes on this site to talk about the benefits and challenges associated with EMR and EHR in their office. As I’ve listened to the various challenges that people have posted, I’m sympathetic to them. However, almost all of those I’ve heard boil down to poor EMR selection or poor EMR implementation.

To me, the EMR selection is the absolute most important part of the EMR implementation process. Far too many doctors and clinics don’t take the time and effort that’s required to really go through a proper EMR selection process. I’m very sympathetic to them for a lot of reasons (ie. It’s not their job or interest, there are 300 EHR vendors, there aren’t great resources for differentiating EHR, there are a lot of perverse incentives, etc). However, it’s worth the cost to do it right. Otherwise, you should wait until you can do it right.

However, I believe that EMR is still only one small part of how healthcare IT is going to impact healthcare. Just last night I was at a local event and someone who use to work in the casino industry has been working for the past year or so on an app that helps improve doctor to doctor communication. Fascinating stuff.

Personally, I see us just at the very begging of a revolution in healthcare IT. IT is going to start invading every part of healthcare and will pretty much be impossible to avoid.

Certainly there will be some (possibly many) who continue to resist the adoption of technology in their clinic. However, I’m seeing more of a shift by patients and doctors that are interested in finding more ways to integrate technology into their healthcare. Most of the doctors aren’t sure what to do next, but they’re looking.

I can certainly understand and appreciate those that say that the current EMR and healthcare IT offerings aren’t up to snuff. The fact is that many of them aren’t. However, that doesn’t change my belief that IT is still going to change how healthcare is provided. It just may mean that healthcare will be changed by an IT offering that most of us don’t know about today.

My greatest wish would be that we could close the case on whether healthcare IT is important and/or it can change healthcare. Instead, let’s put our energy into finding the ways that it can change healthcare IT for good. All of us focused on using healthcare IT and EMR for good in healthcare would produce some amazing results.

Dan Neuwirth is the CEO of MedCPU, provider of the innovative MedCPUAdvisor™ platform: with applications for decision support for clinical guidelines, Meaningful Use, and care pathways, that captures the complete clinical picture in real time, including narrative text and structured data to deliver the most accurate clinical and compliance guidance.

There’s no question that healthcare needs to adopt new technology that makes us more effective and efficient and curbs costs, like Electronic Medical Records (EMR) solutions and Clinical Decision Support (CDS) systems. In today’s world, providers of all sizes continue to find it challenging to integrate existing HIT systems with EMRs for a variety of reasons. As our industry evolves, technology solutions need to be smarter and empower seamless integration.

EMR and HIPAA guest author Susan White covers in depth how a lack of connectivity standards affects EMR integration. There are no mandated standards for EMR vendors to follow, making it hard to coordinate data sharing between medical devices and other systems (including from one EMR to another), even at the same facility. As those systems operate in disparate fashions, critical clinical information is often lost or stuck in silos. Most importantly, the information is not where clinicians need it most–at their fingertips, in an exam room, with a patient.

This lack of data sharing is a pervasive concern. One Markle report finds that roughly 80 percent of both consumers and physicians demand that hospitals and doctors be required to share information that improves coordination of care, cuts unnecessary costs, and reduces medical errors.

In 2010, more than $88 Billion were spent on developing and implementing EHRs, health information exchanges (HIEs) and other health IT initiatives. When you consider that the average 10-physician practice spends more than $137,000 per year on prior authorizations and pharmacy callbacks alone, you’ll have to agree that the lack of data integration and sharing get very costly. And although I agree with John Halamka, who recently wrote these challenges exist because healthcare is inherently more complicated than other industries, I am a strong believer that a lot of them can be overcome by the use of smart technology.

We need smart, flexible solutions, which capitalize on existing technologies and require minimal integration. Technologies that employ advanced screen extraction, for example, empower several important improvements in the clinical decision support space such as the capturing and analysis of both free and structured text. A lot of time such solutions are rendered ineffective as they either lack compatibility with leading EMR systems or are too hard to integrate.

As the industry evolves, developing robust protocols for capturing both structured and unstructured data along with standards for data integration and sharing will become increasingly important. With all the data points created on patients every day, we will need a consistent, secure, and reliable way to capture and share patient data among all systems and healthcare providers. What is your experience? What are top data capturing and integration challenges faced by your organization? Looking forward to continuing the dialog and hearing your feedback.

I know that many of you don’t read all of the past comments made on this site. So, I’m sure many of you missed when DonB asked Bobby Gladd the following question:
Could you explain your statement at the end of the fifth concern: “I would have added another MU criterion: require working with the RECs as a condition of incentive money eligibility;”

Bobby, from this REC blog, offered the following well thought out answer:

HHS is spending nearly a billion dollars on us RECs, yet we then have to go out and “recruit” providers, doing months of cold-call sales?

That just opens the government up to right-wing charges that Obama is simply blindly throwing money around at cross-purposes.

Many vendors and VARs see us as “competition,” which, in my view, is why we’re seeing some of the RECs doing “preferred EHR vendor” deals — basically trying to ensure that they don’t get cut out of the picture. Were I a viable vendor in a REC state that had excluded me, I might want to consider suing. It reeks of potential conflict-of-interest. Moreover, what about the true interest of the clinician? (Which is why we are officially and assiduously “vendor neutral.”)

Why should a practice work with us? Because we have broad and deep expertise available, soup-to-nuts, at a pittance of the cost of private commercial consultants.

It just begs the question of why RECs are even necessary. Maybe we’re not. Maybe docs can go it alone, or pay commercial consulting rates (that would eat up all their incentive money and then some). However, having decided that RECs are a value-adding thing, I fail to see the wisdom in making us optional.

Many of the RECs are going to fail. They won’t even get to demo their implementation/adoption support chops, they will fail because of the recruiting resistance, and will have burned through most of their initial HHS funding, and will have to start laying people off (I won’t be allowing mold to accrue on my CV).

To date, the leading REC in terms of recruitment is Qualis. Halfway through the expected recruitment period, they are at 9.2% of goal, notwithstanding a Code Red All-Hands-On-Deck recruitment effort.

I’ve been meaning to write a post linking to BobbyG’s blog for a while and just never got around to it. If you follow the comments on here, you’ll have seen many of BobbyG’s comments as well. The thing that first struck me about Bobby was his sincere and thoughtful comments on the challenges that the RECs face. Here’s some of his thoughts on REC Challenges:

• Critics bemoan a lack of prior HIT deployment and QI experience among some REC awardees (as well as the heterogeneity of business models);
• While 60 REC contracts have thus far been awarded, with the newly chartered RECs frantically ramping up to meet the rather compressed Stage One Meaningful Use incentive payment timelines, both the requisite Meaningful Use reporting criteria and the EHR (Electronic Health Record) certification regulations remain unresolved at this writing. The cart is seriously out in front of the horses in many respects;
• The anticipated huge and short time-frame new demand for HIT installs may well overwhelm the capacity of HIT vendors, resulting in lengthy, problematic implementation queues (not to mention a severe shortage of qualified installation, training, and support personnel);
• Notwithstanding that HHS is spending hundreds of millions of dollars on REC contracts, physicians and hospitals are not required to engage REC services in order to qualify for federal incentive payments. Consequently, RECs are having to spend significant time and money hawking their services (the polite term being “enrollment.” I did not know when I signed on that I would be required to do what amounts to hastily and minimally trained cold-call sales). Moreover, REC services are not fully subsidized, the upshot of which is often skeptical ”we’ll pass” pushback, especially in light of the hyperbolic claims of virtually all major EHR vendors “guaranteeing” that their products will get the provider to MU (with the glossed-over disclaimer, well down in the fine print”When Used As Directed”);
  • At this writing, the aggregate Final Rule for MU criteria is still under HHS consideration, with myriad professional stakeholder groups arguing for relaxation of both the compressed compliance timelines and the all-or-nothing approach, countered by a broad array of equally vocal consumer/patient advocacy organizations arguing for MU criteria adoption “as-is” as set forth in the Interim Final Rule.

    I would have added another MU criterion: requireworking with the RECs as a condition of incentive money eligibility;

• The relatively sparse per-provider federal REC funding may force the RECs to focus simply on assisting their client physicians with hitting the MU criteria in pursuit of the incentive reimbursements — to the practical exclusion of broader and more sustainable, internalized quality improvement efforts;
• There is to be a “Health IT Research Center” funded by HHS and intended to “gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Extension Centers (RECs) collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support. The HITRC will build a virtual community of shared learning to advance best practices that support providers’ adoption and meaningful use of EHRs.”

  It is not even slated to be up and running until FY2012.

I think most of these points hit the nail on the head. RECs are in for some major challenges. It will be interesting to watch those that creatively confront those challenges and those that fold under the pressure of it all. I still stand by my opinion that they could be a tremendous force for good or bad. Considering there are so many RECs all over the US, I’m sure we’ll have plenty of both types.

There was a pretty interesting thread posted to a LinkedIn group about the RECs. Here’s some comments that will make you think a little bit about the RECs and in particular the RECs working together (or not).

It is understandable that REC’s must adapt their programs to the communities they plan on serving….Healthcare is local. However, living in Florida, where there are 4 REC’s, I expect some things to be consistent…for example the implementation process should include the same pre-implementation workflow worksheet. Unfortunately, this may not happen.

We know that ONC is asking that the REC’s play nice and share best practices. However, as a consultant that is talking with 3 of the 4 REC’s about a role….one REC leader in Florida asked me…”Make no mistake, we are competing with the other RECs, so as a consultant, how will you keep our secrets from the other REC’s you are working with in the State? This was a valid question, which I will address in my agreements, however, it made me think. What are they competing for..additional funding that isn’t there yet? Reputation? Most innovative?

Well..I think its all of the above. I believe, the REC, that employs the right people, have the right vendor PARTNERS, and think outside the ONC box, will rise above the rest. However, best practices must be shared and that is where the ONC project lead/coordinators (in Florida its Kelly), must step up and do!

RECs competing is kind of a sad idea for me. Something doesn’t feel right about that. Now take a look at the compensation funding model for the RECs:

The REC’s do get 500k upfront for marketing the REC, initial staffing needs, etc. Then they get $ as they sign up the physcians, in my area its 5k for primary physicians with no EHR. I think they get 3k for primary physicians that have an EHR, but needs to get too MU. Primary Docs are the main targets though. In terms of competing for physicians….they do not. The REC’s are assigned Counties in their State. The only time they would compete is if a doctor has two offices in separate Counties.

With this followup clarification from another user:

In my state, it’s $1500 for sign up, $1500 upon implementation, $1500 for meaningful use. Perhaps the competitiveness referred to in your conversation with the REC in FL relates to future grant awards…

When you see the $ signs in the RECs eyes, now you’ll know why. I appreciate that the government wants to try and reward results. However, something tells me that this isn’t heading down the path the government intended.

I’ve previously posted a number of posts about the RECs. However, I found this guest post by Bobby Lee was interesting since it looked at how the RECs could significantly influence the EMR vendor market. I’ll be interested to hear your thoughts.

There’s EMR shopping list being created across the country – about sixty of them. Whether or not your favorite EMR vendor makes these lists may determine the vendor’s future viability.

Let me explain.

HITECH Act established Health Information Technology Extension Program which in turn established Health Information Technology Regional Extension Centers (REC). ONC awarded 60 RECs across the country in two rounds of funding (first on 2/12/2010 and second on 4/6/2010) totaling $642 million. Collectively RECs are charged with getting 100,000 priority primary providers (PPCP) to “meaningful use” within 2 years.

These funds are directed for technical assistance and not allowed to be used for purchase of software licenses or any hardware.

So, these sixty Regional Extension Centers are faced with the challenge of guiding 100,000 PPCP to the promise land of Meaningful Use in less than 2 years. EHR is the tool the PPCP must use to achieve Meaningful Use. Given that the #1 barrier to adoption of EMR is cost (by most accounts), the natural tendency is to create a collective bargaining setup similar to Group Purchase Organizations — gather up as many customers (PPCP) as you can, negotiate on behalf these customers with vendors (EHR vendors) with the promise of attentive customers and thus easier sales to vendors.

For this to really work, the list of EMR vendors should be shorter rather than long and value proposition clearly spelled out (who gets what) between all the parties.

Add to this the requirement of ONC for all the RECs to work together and drive toward best practices should enable an environment of sharing amongst the RECs (e.g. similar EHR vendor selection process) such that fewer and fewer vendors should appear on the list ACROSS all RECs. I also believe there’s probably only 20 really “RFP viable” vendors out there for RECs out of 300 (or however many that’s being quoted lately) so called EHR vendors in existence today. These “RFP viable” vendors must be a player in the market with solid experiences ACROSS the States with enough cash and resources to invest ahead of the potential returns as dictated by the terms of agreement RECs will likely negotiate.

In terms of numbers, I guesstimate RECs collective influence at about $100 to $400 million per year (Assume 80% of PPCPs will need to purchase licenses and it costs $100 to $500 per month per provider). On top of that, good portion of the $642 million awarded to RECs will be spent on supporting the work forces across the country learning and doing the work with the EHR vendors that makes the list.

The natural force of RECs driving the “crowdsourcing” takes over and at the end of few cycles (e.g. stages 1, 2 and 3 of MU requirements), three to five vendors will bubble up to be the “it” vendors. If they don’t screw up too much, the infusion of licenses & revenue will further drive the divide between the “haves” and “have-nots” and will further solidify the vendor landscape with less number of EHR vendors in the market place.

What do you think?

About Bobby:

Bobby Lee is the Principal and co-founder of eRECORDS, Inc., Health IT consulting firm.  Prior to starting eRECORDS, Bobby was President & CEO of NGHN, Inc., a non-profit EHR management service organization started with a competitive grant award.  Bobby specializes in the application of connected technologies, information and processes to improve access and quality of care in community clinics and practices.  You can reach Bobby atbobby.lee@eRecords.com or visit www.eRecords.com.

I came across an interesting idea today from the Change Now 4 Health community where they are giving away $10k for the best healthcare idea. They are calling it Innovation xChange. Here’s a summary of what they’re trying to do:

Do you want to improve the U.S. health care system? Or at least be part of the much-needed dialogue?

If you have ideas or solutions to improve the system, submit your ideas through ChangeNow4Health’s Innovation xChange and you can win up to $10,000 or have your ideas published in the e-book, Tomorrow’s Health Care.

The Innovation xChange is looking for practical ideas and suggestions for improving the health care system. All participants in the system, from providers and health plans to consumers and government, are encouraged to join in the discussion.

$10k isn’t a ton of money, but for just submitting an idea it’s not too bad. It’ll be interesting to see what happens with the contest and what kind of creative ideas come out of it. I wonder if any EMR applications or EMR features will make it into the contest.