Time to go through some interesting Tweets from the world of EMR and EHR.

@glevin1 – gary levin
Commodization of EMR | HealthWorks Collective

There was a link on this tweet too, but it looked like a link to a page that stole the content from the original article. I’ve been intrigued by the question of whether EMR is a commodity software or not for a while now. I still haven’t come to a firm conclusion. This article uses the idea that you can buy Allscripts MyWay at Costco as a way to say that EMR is a commodity. You can also buy eCW at Sam’s Club I believe. Although, as best I can tell, that was basically a PR move on the various EHR vendors part.

Also, the article says that Allscripts MyWay product came from the purchase of Misys. Actually, I think MyWay was originally Aprima. I believe the Misys EHR software is set to be sunset.

What do you think? Is EMR a commodity?

@BrianSMcGowan – Brian S. McGowan PhD
Percent of US PCPs using EMR = 17% in ’00′ – 28% in ’06′ – 46% in ’09′ (vs 99% in Netherlands) #socialQI #progress??

The link on this one was to a terribly long PDF file. So, I cut it out. I just wish I knew where Brian got his numbers. I call BS on the US having 46% EHR adoption in 2009. I still put us at about 25% EHR adoption now. Maybe a little higher if I’m being generous. Of course, a lot of people define EHR a lot of different ways. So, that might be part of the issue.

@DRZORBA – Zorba Paster
Back to the clinic. Everyone brings their records with them. No EMR here. If they lose their record then they’re @*%&M.

Hmm…imagine a world where the doctor didn’t keep any record. The patient was just responsible for the record. That idea is fraught with trouble and issues, but I bet many doctors would love to not have to worry about the records part of their job.

@medreccom – Medical Records
“Paper is dangerous and inefficient, it doesn’t belong in health care any longer.” Future of #EMR: on.mash.to/uhVkHn

I was interested in this tweet since it linked to an article on Mashable (a mainstream tech site). So, if I get this right, this article and series was sponsored (ie. paid for) by Lenovo and profiles Practice Fusion. In other words, Lenovo paid to advertise Practice Fusion on Mashable. Good for Practice Fusion. Although, I’m not sure how many doctors read Mashable. Maybe the article wasn’t about finding doctors, but was a way to find more tech people to come work at Practice Fusion. The article itself is pretty basic for someone that reads this site. Not a bad play if that was the intent. Full Disclosure: Practice Fusion advertises on this site. Although, they certainly didn’t pay me to write about this and link to it.

Some 10 years ago, when I first started covering health IT, a lot of the talk was about the “modular” approach to EMR adoption, i.e., put in a piece at a time during a transition period. Much of that had to do with the state of technology at the tail end of the dot-com bubble, when companies developed applications to address one small problem, often in the hopes of getting a larger firm to shell out big bucks for their idea. (Wouldn’t you know, that’s how many vendors, most notably GE Healthcare, put together end-to-end enterprise systems.)

Implicit in any step-by-step transition to EMRs was the idea that there would be an interim period where providers would have to run dual electronic and paper systems. It’s a notion that’s always been with us, but how many people still think of it?

I got a reminder this afternoon when I spoke to Ken Rubin, Iron Mountain‘s senior VP and GM for healthcare, who was talking about results of a new survey on progress toward meaningful use. (I was ostensibly doing that interview for InformationWeek Healthcare, so look there tomorrow for coverage. Here, I just want to talk about one aspect of the conversation.) Rubin noted that there seems to be a sort of “no-man’s land” between the paper and digital. “I don’t see a real, well-defined way of dealing with the hybrid world,” when hospitals and medical systems are switching to EMRs while still retaining old paper records.

Obviously, Iron Mountain would like to sell some scanning, data management and shredding services to healthcare organizations, but Rubin has a point. The rules for meaningful use Stage 1 don’t say a thing about what you’re supposed to do with existing paper files, and it doesn’t appear that Stage 2 will address that issue either.

Do you scan all the old files immediately, or wait until each patient’s next visit, then chart electronically going forward? What do you do with the files of inactive patients? Do you archive records in house or offsite? Do you still need rows of files taking up valuable square footage that could be put to better use? What do you do with clerical staff?  Do file clerks become managers of electronic health information, or do you need to replace those people with others trained in HIM?

Rubin noted that this limbo often works against organizations trying to overcome physician resistance to change. “The faster you can get to the other side, the faster you’ll get physician adoption,” he said.

That all makes good sense to me. CIOs and practice managers, what do you think? Have you addressed hybrid workflow during this transition period, or is the siren call of federal dollars for meaningful use too strong?

Sometimes when we think about EMR, I think we forget about the subtle nuances of paper charts that make them so undesirable. Check out this story which I got in response to my post called “Think About the Problems with Paper Charting.” It’s a a good illustration of some of the more simple things we often forget about:

I was recently visiting a relative at a major teaching hospital in the Midwest. While in the hall I noticed that they had charts in binders stored in boxes affixed to the wall. Just as I was wondering why such a prestigious institution relied on paper charts a nurse went to re-insert a chart into its box. She was in a hurry and missed, the chart dropped to the floor and binder opened and paper went all over the hall. What was even more surreal was the nurse did not at fist notice her mistake and was at leas 6 feet away before she noticed it and fixed her error.

Sometimes it’s not what you get from an EMR, but what you don’t get that matters.

Back in April, Evan Steele, CEO of SRSsoft, wrote an interesting post about EMR adoption and he asked the question, “Why Are You Still on the Fence?” It’s a very good question. Plus, he adds some value to the conversation by listing some of the problems with paper charts versus an EMR. Here’s a section of his post:

So why are these physicians, who have determined that government incentives are not relevant or achievable, still on the fence about adopting an EMR solution that will deliver measurable benefits? Staying with paper charts is not a good business strategy because there is nothing more inefficient!

• The costs associated with the excess staff needed to manage these medical records are massive and wasteful—these positions can be eliminated or the employees can be more effectively used in revenue-generating or patient-care roles.
• Paper charts hinder practice growth because adding physicians requires a proportional increase in support staff—medical records, billing, nurses, and medical assistants—and because physicians can’t see more patients without lengthening their work hours.
• Slow responsiveness to primary care physicians limits referral volume.
• Profitability is further affected by billing bottlenecks that delay revenue collection.
• The chaos associated with trying to manage paper charts has a damaging effect on staff morale and creates rampant frustration among patients, physicians, and staff.
• Paper charts are a malpractice nightmare—prescriptions are not consistently documented, orders are not easily tracked, and medical decisions are often made without complete clinical information.

So, why are doctors on the fence with EMR? The sad thing for me was the pre-EMR stimulus money, I felt a shift in the tone of conversation around EMR adoption. Doctors had mostly moved from wondering if they should implement an EMR to how they should implement an EMR and which EMR they should implement. They were off of the fence and I saw the tide shifting.

And then in one anti-stimulative swoop, the HITECH act rolled out and doctors decided to go back to the sidelines and see this government incentive play out. Now they’re waiting for meaningful use to be defined. While the HITECH act has increased EMR awareness 10 fold, it’s also done much damage on the short term EMR adoption. I’m not sure that the increased awareness will overcome the damage that it’s caused.

Of course, the damage is done and so we have to go forward from here. I suggest we go back to pre-EMR stimulus times and focus more effort back on the benefits of EMR and the costs of paper instead of the government handouts. If we do that, we’ll see a fantastic shift to more widespread EMR adoption.

I’ve previously written about chart disposal after an EMR implementation and the concept of “thinning your paper chart for scanning into an EMR.” Because of those posts, one reader asked me about feedback on a list of what things should be included in the “thinned” paper chart.

Of course, my first reaction was to tell them to ask the doctors. Each doctor/specialty/clinic is unique and so every one of those would have their own list of what they thought was important. However, I also said I’d post their list on here for people to take a look at and provide feedback on things that shouldn’t be on the list or things that might be missing from this list. So, check out this list and I’d love to hear feedback on it in the comments:

Paper Chart to EMR Scanning List (in no particular order):
Birth records, Nursery, NICU, State Screen, Type/cross.
Growth Charts front and back.
Immunization record (multiples may exist, scan all).
Master Problem List.
Chronic/incidental/PRN medications.
Allergies/sensitivities.
All prior well child checks.
School/Scout/etc PE’s.
All acute visits if chronically ill, otherwise do not include uncomplicated CCD.
All special evaluations (ADHD/Feeding/Nutrition etc done in house).
All referral and specialists’ consults/findings.
Family History if known. Adoption may prohibit this.
City water vs well water.
Lab reports – baselines and all if chronic medical issues.
All diagnostic imaging reports.
Insurance history.
Demographic sheet/all address changes.
All legal documents – custody/state/adoption/POA/living will etc.

A look at this list makes me think about what types of things might be useful when exchanging patient records electronically. Seems like the concept of thinning the chart and exchanging data might be worth considering together.

In my previous post I talked about a few of the options related to shredding or archiving your paper charts after you’ve implemented an EMR and the paper charts aren’t being accessed.

Now let’s take a look at what’s just begun to come up in our clinic: EMR Data Archiving

Archiving Old EMR Records
Once you’ve been on an EMR for a number of years, you start to think about all of the data that’s stored in your EMR. Do you really want to store ALL of the information you’ve entered into an EMR in perpetuity? The answer as usual is maybe.

Quick Disclaimer: Before you do any EMR data archiving, you better talk to a good lawyer to make sure what you’re doing is legal in your state. I am not a lawyer and don’t even play one on TV. Just don’t be surprised if your lawyer say there’s no case law on this and so they’ll only be able to give you a best guess.

Now back to the point. The concepts in this are very similar to retention of paper charts. In fact, I’m guessing the laws for this will be similar to the laws on retention of paper charts.

On the one hand, it’s a great thing to be able to have years and years of a patient’s history available to you at the click of the button. In fact, in certain cases where you’re dealing with chronic conditions having all of the EMR data forever could be VERY valuable.

However, I see two possible problems with retaining all of your EMR data forever. First, there is a potential liability issue if you retain all of those records which are very old. If you’ve disposed of the data properly and according to state and federal laws, then you are no longer liable for the removed information that’s stored in the EMR. The second issue is that your EMR database grows larger and larger each year you use your EMR. Between all of the data that’s entered in the EMR and all the various scanned documents that are added to the EMR, the size of the database can be a huge issue after a number of years.

I’ll leave the first problem of liability to the lawyers. The second problem is really interesting. As your database grows, now database backups go from 5 minutes to sometimes hours (in some cases). Restoring all of that data will take a long time as well. At some point your server can run out of disk space for your database and will you even notice that it’s out of space before it’s too late and your server is in trouble? These are just a few of the issues related to storing all of your EMR data forever.

I don’t know of any EMR company that has implemented a solution for this problem. Although, it’s theoretically possible that you could extract the data from your EMR that was previous to a certain date. There could be multiple options with that data. For those concerned about liability, they could delete the extracted data and it would be gone forever. For those just concerned with the database size, you could move the extracted data onto another device or even just saved in a safe location (probably more than one location). In fact, you could even add it as its own database and your EMR company could give you a way to switch to the “archived EMR database” to see all of the archived data. Doing this will make your EMR database much smaller and much more manageable.

I have a feeling this post might have gotten a little too technical. Oh well, I guess sometimes the tech guy in me just comes out.

Also, lest someone starts typing a comment that the database will never get that big to matter. Be careful in saying never. Between scanned image files which are getting bigger and bigger as the quality improves and just the sheer length of time that people have owned an EMR this can happen. In fact, it has happened.

I’d be planning on posting about this for a while and someone brought it up in the comments of one of my other posts. So I figure it must be time to talk about what to do with all those old paper charts. I’m not going to go into the specific regulations. First, I’m not a lawyer and don’t want to give any legal advice. Second, these regulations often vary from state to state and 50 is a lot of different regulations.

With that disclaimer, let’s take a look first at what to do with all the old paper charts that are no longer being accessed.

Archiving or Shredding Old Paper Charts
One of the big questions people ask is what do we do with the old paper charts. In this post I’m not going to talk about the various ways that you can incorporate your old paper charts into your EMR workflow. I’ve covered that a number of times before including my post about thinning your paper chart.

Instead let’s talk about what you do after you’ve had an EMR for a reasonable amount of time and you find that you’re no longer pulling paper charts on a regular basis. You might still pull the paper chart on some rare occasion, but for the most part the information you need is now in your EMR.

In my office, we chose to hire an outside company to take our paper charts and scan them into a little program for us. This did cost a bit, but it’s nice to have all of those old paper charts in a nice indexed format that we can quickly search and print out if someone requests their old records. You can even put it on a web server and do some partial integration with the program we store all these old scanned paper charts with our EMR. However, we haven’t needed to do that since medical records is the only one who ends up really accessing the charts.

Of course, the other option that I think many people do is just store them somewhere. This isn’t a horrible option since it can be in a part of your office that isn’t being utilized. It can even be off site if it’s cheaper to store it somewhere else. However, you just have to be careful of course that the location is still secured properly.

Are there other options available to those dealing with the old paper charts after implementing an EMR?

Tomorrow, I’ll follow up with a post on archiving your EMR records.

Do we really know the true benefits of EMR or can we not find them out until we have them implemented?

This is a question which has been on my mind a lot lately as I’ve been reading and writing about Obama and EMR.  There have been so many different studies describing the effectiveness of electronic medical records.  Some show the amazing benefits of an EMR.  Others have shown that electronic medical records aren’t everything we hoped they’d be.

As I think about these two differing opinions, I can’t help but think that we probably don’t know the benefits that can come from having broad EMR adoption.

Certainly many studies and those interested in EMR have evaluated the fiscal and clinical benefits of an EMR.  I just can’t help but wonder if we won’t be able to understand and measure the benefits of EMR until broad EMR adoption occurs.

Just think of a few simple things we could do so much better with aggregating EMR data:

• Disease Tracking and Outbreaks
• Drug Effectiveness
• Drug Side Effects
• Health Trends
• Detialed Past Family/Medical History

I’m sure this list is inadequate in expressing my feeling that a broad adoption of EMR will open up a world of data that was previously stuck in the depths of a paper chart.

Today, I decided to start a new web page that I believe will really grow over time. It’s basically a list of the possible benefits a doctor or clinic can receive from using an EMR or EHR rather than paper charts.

I haven’t take much time to make the list at all, but I think it’s better to start it and then as ideas come to my head I can add to it as time permits. I already have a number of other ideas (like quality of medical care), but I need some more free time to put all the details down. Now that I’m thinking about it a little bit more, maybe each benefit of an EMR should have it’s very own blog post describing the benefit that’s received by using EMR. We’ll see how that works. Seems like a worthwhile series of posts to me.

Also, in all fairness I’m certain that I’ll also soon be creating a list of problems associated with EMR. I think it’s important to keep the discussion well rounded and that people are well aware of both the benefits and challenges associated with using an EMR.

Finally, I certainly welcome comments from people on benefits or challenges associated with use of an EMR. I look forward to hearing ideas from other people’s experience to help me round out the list of benefits and challenges that many have already experienced first hand. Might as well try to pass on that knowledge to those who are still implementing or looking to implement.