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 I mentioned in my last post, I’m going to take some time over the next week or so to look ahead to 2012 and discuss what I think is going to happen in the world of EMR and health IT. Since today is the regularly scheduled Meaningful Use Monday, I decided that it would be appropriate to take a look forward at Meaningful Use in 2012.

In many ways, 2012 is not going to see any major public shifts in meaningful use. Sure, we’re going to learn more about meaningful use stage 2, we’re also going to finally get out of the temporary EHR certification to the permanent EHR certification (unless something crazy happens). Although, I don’t think either of those things are going to make much real difference in the lives of doctors. Instead, there’s going to be an undercurrent of other trends that shape the future of EHR incentives and meaningful use.

Here we go:

Doctors First Hand Experiences – As Dr. Koriwchak notes in his physician perspective on meaningful use, there aren’t that many first hand experiences out there from physicians discussing their experience with meaningful use. Most of what you find out there are physicians that have been asked by their EHR vendor to be the face of that EHR vendor’s meaningful use efforts.

In 2012, whether published publicly or heard through the grapevine, doctors first hand experience with EMR implementations, EHR incentive and meaningful use are going to start filtering through the medical community. I bet Dr. Koriwchak isn’t going to be alone in his assessment that basically, I survived meaningful use, but recommend staying away. If this is the message about meaningful use that spreads, then expect more people like Dr. West opting out of Medicare or just accepting the possible EHR penalties.

Meaningful Use Audits – We know that audits of those who took EHR incentive money are coming. I think that CMS (I think they have authority over this, right?) will be generous with their audits. They won’t make it easy and fun for the person who gets audited and fails. However, I don’t think they’re going to try and make a public disgrace of those that have their meaningful use attestation audited. Doing so would set back the entire program. Instead I think CMS will try and spread the message that they’re serious about honest meaningful use attestation, but that they’ll be reasonable in their approach.

Checks Flowing Ok, so it won’t really be checks since most of the payments are going to be wired into doctors bank accounts, but you get the idea. Either way, there’s going to be a lot of doctors that are finally going to get paid for their EHR effort in 2012. This will no doubt invoke some portion of envy in their physician peers. I know I’d hate having my doctor friend getting a check and me not getting it. I felt this same way when people were buying houses and getting the government money for buying a house a couple years ago. Doctors won’t be immune to this sort of “jealousy” of their peers.

The real question is whether the money flowing will be a stronger force on EHR adoption or whether the above mentioned meaningful use pains will be stronger. As you see in my next two predictions, I think it is a split verdict.

Hospitals Capitalize – My best prediction is that hospitals will see the money flowing and be unable to resist following the money line. We’ve already largely seen this shift in hospitals IT projects. I know a number of healthcare entrepreneurs who have said that hospitals aren’t really doing any major IT projects outside of meaningful use. Hospitals will continue this trend and will likely end up taking the majority of the EHR stimulus money that’s being paid out.

Small Doctors Offices Stay Away – As I wrote about previously, most EHR incentive money is being paid to existing EHR users. In 2012 we’ll be moving past those existing EHR users and I predict that most small doctors offices will continue to sit on the sideline of EHR. The money isn’t large enough for small doctors to overcome all the work required for them to implement an EHR and the EHR penalties are a drop in the bucket for most of these doctors.

I imagine that many will be thinking, “What about the other EHR benefits beyond EHR stimulus money?” To that I’d say, you’re absolutely right. There are plenty of other benefits to having an EHR that don’t include government money for EHR. Unfortunately, the free government money has created this myopic view of the world where those other benefits have lost all their appeal.

Ok, you’re turn. Any other things you see happening with meaningful use in 2012? Any of my meaningful use predictions that you disagree with?

The readers of EMR and HIPAA have been incredible lately in sending in great commentary on the EMR industry. The following is one such commentary about the issues associated with the now widely seen trend of Hospitals acquiring practices. The person asked to remain anonymous and for the names of the specific EHR vendors to be removed. I agreed since I think the trend is more important than the specific companies.

One trend that I find extremely (and personally) troublesome is the migration from homegrown EMR’s to less functional Hospital based EMR’s – a migration that is occurring frequently now that most small practices are being purchased by Hospitals.

In our case, our small hospital administration decided unilaterally (without MD input) to implement a poorly designed EMR from it’s IT vendor. This has been a colossal failure, as none of the doctors were able to use the EMR. Hospitals are easily seduced by their IT vendors, and think that they can have only one software vendor. They think that all EMR’s are basically the same, either a Ford or a Chevy mentality. They don’t want the docs interfering with the decision process. They don’t have any idea of information and work flow in a doctor’s office. And now they are getting ARRA stimulus funds, and sometimes grant money from local endowments.

We doctors have asked that administration find us one practice that is successfully using the EMR they selected. I think they found 1 doctor 1,300 miles away who was able to make it tolerable. The hospital EMR is CHIT certified, so that doesn’t mean much. Hospital Software vendors have quickly tacked together some sloppy EMR’s in order to save their customer base, and have easily deceived administrators into buying these inferior products.

Our administration has pulled back from implementation, just having us use the scheduler, nursing putting in vitals/meds, and we just enter the ICD-9′s and charges. But another push to MU is coming soon. I have told admin that they must cut my daily schedule from 20 to 10 patients per day. I think that the ARRA stimulus funds and this whole Medicare push for EMR is having a negative effect so far, as least for me. I was using [EMR Vendor] (and still am unilaterally) to organize my data, and generate notes. It’s light years ahead of the EMR the software vendor selected.

I have heard my story repeated many times. The trend of Hospital owned practices may be inevitable, but it has severe negative consequences for EMR, in my opinion.

John’s Comments: While I don’t necessarily agree with the broad ranging comments about administrators not caring or listening to doctors, I’ve heard it far too many times to disagree completely. There’s little doubt from my experience that many hospitals don’t do a great job listening to doctors in selecting an EMR software. However, I’ve also seen many doctors who are terrible to work with when it comes to any discussion of an EMR. So, let’s not kid ourselves into thinking that the doctors are completely blameless either.

One important point that is made is that doctors like using EMR software that they select. As more and more hospitals acquire practices, this issue is going to come to a head. I won’t be surprised if it’s actually a major part of the reason that the cycle of independent doctors starts again.

As many of you know, when an EMR or EHR vendor wants to show me their system, instead of getting a full demo of their EMR I instead ask them to show me the unique features of their EMR. Basically, I’m interested in seeing the features, functions, approach, etc that makes an EMR or EHR vendor unique from the 300+ other EMR companies in the market today. This was my approach when EPOWERdoc approached me with a request to take a look at what they’ve created with their EMRDoc software.

Turns out that EPOWERdoc has been around for 12 years and is already in 250 hospitals in 40 states. That’s a pretty good footprint for an Emergency Department comnpany. In fact, I read that they’ve done 17 million Emergency Department visits in North America in their 12 year ED EHR history. Of course, these numbers come from EPOWERdoc and we know how good EMR install counts are from EMR vendors. However, even if that numbers bloated it’s a decent sized install base. Update from EPOWERdoc: The client numbers and ED visits are correct, we started out as a Paper Template system from software printing and that is where the large client base is predominantly. We are 36 months into the EDIS market with the product you looked at and have 18 live and another 9 by first qtr 2012.

During the short demo, EPOWERdoc showed me 3 or 4 interesting things about their Drummond Group modularly certified EHR. However, the feature that hit me most was the EMRDoc prose generator. In fact, this demo was one of the reasons that I’ve started predicting an EMR documentation revolution against hard to read, bulky, clinical notes.

I wish EPOWERdoc had a video of their EMR notes prose generator to demo it. If they create a video, I’ll post it to my EMR, EHR and Healthcare IT videos website. Until then, here are before and after screenshots of the EPOWERdoc interface which shows the granular data entry and the note that was created (click on the image to see the full image).

And now the image of the outputted documentation:

We could certainly debate the finer points of the user interface for inputting the data. Plus, a screenshot doesn’t show some of the other elements they’ve created to be able to quickly handle the input of the granular data elements. What hit me was how much the second image read like a clinical note. To be honest, as I read it I felt like I was hearing someone dictating a clinical note. Are their subtle differences where dictation is better, definitely. However, they seem to have done a good job of taking the granular data and turning it into clinical prose. I’ll be interested to hear some doctors thoughts on the above to see if they agree or disagree.

There were a few other interesting EMRDoc features that stood out to me in my short EMR demo.
-As an ED EMR, you have a different workflow than an ambulatory practice. As such, you need the ability to manage multiple open records at the same time. What I think EMRDoc does really well is switching between patients, but then also tracking your last documentation location for that patient.
-Related to seeing multiple patients, EMRDoc documentation feedback tool provides the user (doctor, nurse, etc) with a real time feedback as to the status of the level of documentation for medical coding as well as what has been completed in the note. In the ED where you’re regularly pulled away to deal with a pressing problem, the feedback statuses are a great little feature.
-EMRDoc has a feature that forwards clinical information and data from the Nursing Record to the Physician Record and from various sections of the Physician Record to other sections. Pretty slick implementation that reduces having to document that same thing multiple times.
-One of the big questions for an ED EHR like EPOWERdoc is how they deal with the hospitals large HIS system. EPOWERdoc’s answer was a partnership with Iatric who uses technology allowing data insertion into non accepting systems such as Epic, Cerner, McKesson or Meditech. I’d seen Iatric (They had the amazing trick shot pool table guy at HIMSS), but it sound like I should get to know them a little more. Maybe I can get Katherine Rourke to cover them over on Hospital EMR and EHR as well.

As I said, I didn’t do a full scale top to bottom demo of the EMRDoc ED EHR system, but I thought these were some interesting features of their EHR that were worth sharing. I’d love to hear some first hand experiences from any EPOWERdoc users. Let’s hear what you think in the comments.

As many of you probably know, I started a new Hospital EMR and EHR website that follows a similar pattern to EMR and HIPAA & EMR and EHR, but focused on the technology used in a hospital with the EHR being at the center (most of the times). The site has been growing like crazy with the wonderful Katherine Rourke posting most of the content.

However, one thing I found really interesting was that I took this post about Epic Possibly Being Victim of its Own EMR Success and posted it on Google Plus (UPDATE: You’ll need to add me to your Google Circle so I can add you to my EMR circle to see it. I forgot I only shared it with my EMR google circle and I can’t see how to make it public). I’ve just been dabbling around in Google Plus, and so I was surprised by the results.

In the post itself, there have been 6 comments about Epic EMR’s success. That’s really not a bad number of comments for such a new Hospital EMR blog.

However, the astounding part is that my thread on Google Plus that links to the post has already had 40 comments on it with some amazing insight from those commenting.

It’s still really early in the life of Google Plus. Maybe it’s early and the novelty of Google Plus is what’s currently providing the great discussion. I’ll have to seriously consider how I can incorporate that discussion into future blog posts.

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.

Guest Post: I got the following story that someone wanted to share about the challenges of EMR and workflow in a hospital. I love reading first hand experiences with EMR. Reminds me of a great experience that Neil Versel documented at an urgent care during HIMSS. I look forward to hearing your comments on the story.

Last month, my wife felt some discomfort in her chest. They weren’t pains, nor were they indigestion so much as a gurgling sensation. After two days and no change, she called our family physician. He told her she could come in for a blood enzyme test, but the lab result would take four days. Instead, he said to go to an ER where they could get the result in half an hour.

That evening, a Friday, we went to the nearest ER, at Large, Modern, Suburban DC hospital (LMSDC.) We walked right up to the triage nurse, a woman in her 60s who stood there and took down my wife’s info on paper: Name, Chief Complaint, Age, and Triage Class, a 3. We were handed the paper, the only copy, and sent to the first of what would be three exam rooms.

The room was for EKGs. It was equipped with a machine, bed, etc., and a desktop PC. After a few minutes, a tech came in and ran the test. I asked how the scan got into my wife’s record. She told us it was sent electronically to imaging where it would be reviewed and put in the record, but she didn’t know how it was entered, electronically or scanned in.

We had three more visitors, two nurses and an admissions clerk. Admissions came in with a COW, a computer on wheels. She started asking demographics, insurance, etc., but was called away. The first nurse came in went over why we were there, about meds, etc., took a blood sample and did something on the room PC and left.

The second nurse came in, went over symptoms, meds, etc., again, and scribbled the information on a scrap of paper in her hand. We never saw either nurse again. While waiting for the next step, I saw that the first nurse had logged into the PC, but not logged out.

We were then moved to a small exam area with five beds to wait for an attending and to wait for four hours until time for another blood sample. The area was run by a tech I’ll call Sam. Sam was a remarkable multitasker. Among other things, we saw him:
• Arrange patients and families in the cramped space
• Look for other staff
• Take blood
• Check orders
• Organize a stack of loose forms into their patient clipboards
• Change bed sheets
• Check the EMR for updates
• Check on patient moves

Sam did all this, and from what I could tell, was the only person who was actually followed the different aspects of his cases.

At first, the area was at capacity with crying children, their worried parents and others typical of a Friday night in an ER. While Sam directed traffic, the admissions clerk caught up with us and finished my wife’s record.

Around nine, an attending came in. He stopped midway in review for a half hour cell call and then returned. He recommended that she should go on a heart monitor and stay overnight. After the attending’s visit, we settled down to wait for a room. Sam checked every now and then to see where it stood, but it went nowhere.

About eleven, while making my second run to the ER vending machines, I saw the attending and mentioned that it was getting pretty boring waiting for a room and a monitor. Surprised, he said he’d ordered the monitor and that it should have been put on in the ER. With that, he checked with the charge nurse to get it done. The charge nurse came to see us and had us move to another area with a monitor, which a nurse started. Just after midnight, still waiting for a room, my wife sent me home. She called about one to say she’d been moved to a medical floor and was on a monitor.

I knew that LMSDC adopted an EMR three years ago and, indeed, it was clear that meds, complaints, orders, etc., were being entered into it. However, it was also clear that their system was a receptacle not a workflow tool. Apparently, LMSDC simply overlaid the EMR on its paper system, eliminating some parts, but keeping others. These other elements persist in their own parallel world. For someone such as Sam, who tries to keep his patients current it means more work not less. This explains why he had to deal with the EMR and constantly sort and organize paper forms into their proper patient clipboards.

Even that is not LMSDC’s major ER workflow problem. The heart monitor problem shows there is no shared task list. That is, once the attending entered the order, and I believe he did, the order is in the EMR. However, who is to carry it out and when should become a task that all others can see. Thus, the conversations among the attending, the charge nurse, Sam, my wife and me should have been unnecessary.

A couple of gratuitous points. LMSDC’s system is heavy on desktop machines. It cries for laptops or pads. Nurses, techs, attendings spend their time flying from one desktop to another, logging in and, sometimes, out. It’s a machine centric rather than a user centric system. Users never have their own workspace. They are always in hit and run mode. Even if they have a good system workflow and a good shared task list, they spend enormous time and energy logging in and out of room machines. It’s no wonder things get lost in the cracks.

LMSDC’s system runs both patients and staff ragged in another way. We moved three times, no record I expect. Nurses came and went. The attending should have been on skates. The only one with a dedicated space was Sam which explains why he could get so much done without exhaustion. How much easier their difficult lives and their patient’s lives would be if the patients came to the staff rather than endure the ER’s fast action minuet.

What’s so amazing is that despite their poor IT support and their constant motion, the staff was invariably professional, focused and friendly.

Best of all, after a night in the ER and a morning on a medical floor, my wife was discharged. She’s fine.

Many people have been arguing that it’s an easier process for hospitals to be able to justify the implementation of an EHR thanks to the new EHR stimulus money. Even more important might be the 5% penalty for not implementing an EHR.

There’s no doubt that there’s a lot of money at stake in a large hospital system that has 100+ practices. You can do the math: number of providers x $44,000 = A lot of money. However you also have to add to that amount the penalties which is basically: Medcare reimbursement x 5% = Even more money.

I’m certain that every hospital in the US is keeping a close eye on these developments. Even large group practices have some of the same financial equations with just a little bit smaller scale.

What I think most people are forgetting is that there’s a reason most of these hospitals haven’t implemented an EHR. It’s not a simple task. We’re talking about getting hundreds or providers with even a larger number of workflows to agree on an EHR system and then implement it across multiple specialties.

I’ve talked about my experience before visiting what I believe is one of the largest EHR implementations in the US of its kind. They have 100 multi specialty clinics and have been working on their EHR implementation for at least 3 years (if my memory serves me right) when I met with them. After all these years of implementing they were still at about 25% implementation.

Not only had they only been able to implement that small percentage of practices, but they were also just starting to butt up against some major resistance based on the first 25% of practices implemented. Add on top of that the EHR vendor’s ability to support such a large implementation and they were running into some real slow downs.

Now I think this practice had made some real progress and had some pretty strong leadership at the top to even get where they were at the time. However, my point is that even with the best of intentions, these large hospital systems are going to have a major major challenge trying to implement such a large number of EHR in order to receive the ARRA money. Certainly there’s a lot of money at stake, but there’s also certain laws of time frames that makes this an almost impossible task to accomplish in the ARRA timeline.

The crazy thing is I haven’t even really talked about meaningful use in this post. I’m just talking about implementing the EHR and getting doctors to use it. Then, what effort will be required on top of that to show meaningful use of an EHR?