EMR and HIPAA

The Current Health IT and EHR Bubble

John — Wed, 16 May 2012 14:39:57 +0000

I had a really great conversation with Shahid Shah, Jenny Laurello and John Moore at Health 2.0 about the bubble that we’re sitting in right now. John Moore’s response to my question, “When do you think the bubble will pop?” was priceless: “Which bubble?” Yes, we might be seeing multiple bubbles in healthcare IT: EHR, HIE, mobile health, etc.

For this blog, I’m most interested in the EHR bubble. Obviously, the bubble in this case is the creation of the $36 billion in EHR stimulus money that’s being handed out thanks to ARRA and the HITECH act. With over 600+ EHR vendors and a limited number of customers (I think there’s about 700,000 physicians in the US), there are going to be quite a few EHR vendors that won’t make it.

With that said, I don’t think the EHR bubble will pop like it has in other industries. In fact, I think the current IT industry bubble is going to be a much bigger problem. What’s amazing to me is how you can make a decent EHR business with only a few hundred doctors. Sure, a few hundred doctors won’t create 10 times return to investors, but those who take a conservative approach to building their EHR company could get by with what I believe is an astoundingly small customer base. Physicians are just that valuable.

Shahid Shah described EHR as a cottage industry and so cottage EHR companies will survive. I’m not exactly sure how he’d described cottage industry, but I think the regional nature of healthcare is definitely an influence on this. I’m sure many could argue that long term this strategy won’t work, but I believe at least for the forseeable future we’re not going to see the EHR bubble pop for a while.

As I think about the EHR companies I know, they all seem to have plenty of cash to make it through meaningful use stage 2 and likely all the way to meaningful use stage 3 at least. We’ll see how the smaller EHR companies do post meaningful use stage 2, but I don’t see any EHR vendors not making it to meaningful use stage 2. They’ll at least make it to MU stage 2. Then, based on their adoption results (or not) we may see a few EHR vendors run out of money.

What do you think? Are we in an EHR bubble? When will the EHR bubble pop? What other healthcare IT bubbles do you see?

Making the Case for EMR VARs

John — Tue, 15 May 2012 15:18:28 +0000

In the comments of a post by Dr. Gregg, someone made a really interesting case for going with an EMR VAR instead of the EMR vendor itself. Of course, this commenter was named “EMRVAR” which probably means they come from a VAR. So, you have to take these comments with a grain of salt, but their comments are worth considering. Here’s the case they made for VARs.

My Advice: Seek out a VAR – Value Added Reseller that cares more about you and your practice then any BIG NAME EMR CORPORATION that only cares about its stock valuation on any given day.

VARS

A VAR is an advocate for your practice – a Var’s many installs weigh more heavily than any one customer that the BIG EMR Corp has.

A VAR deploys technology from several vendors and adapts these products and services to its customer specific needs

A VAR partners with several product manufacturers and service providers. Though partnerships are formed, it is important to realize that a VAR is an independently owned and operated business that is not bound by any one corporation products, services and policies.

A VAR is often located locally to the communities it serves

The VAR model is important in healthcare and the above comments state a pretty good case for the EMR VAR. I find it interesting that in many respects this is the case that small EHR vendors make as well.

What has been your experience with EMR VARs?

Government Healthcare IT Dashboard from ONC

John — Mon, 14 May 2012 14:40:30 +0000

One movement that I and I’m sure many of you have seen unfolding by HHS and ONC in particular is what Todd Park calls Data Liberacion. As Todd Park has moved to CTO of the US, I expect he’s going to take the data liberation movement beyond healthcare.

The latest addition to the Healthcare Data Liberation movement by ONC is the Health IT Dashboard that was put up by ONC.

Here’s the description of what’s possible for the website:
The Dashboard currently provides summary information about all ONC HITECH grant programs, and detailed data from the Regional Extension Center, and Community College Consortia to Educate Health IT Professionals programs.

Using ONC’s Health IT Dashboard, you can:

Generate maps of health IT adoption statistics for common groups of health care providers & hospitals,
Examine the impact of ONC’s Recovery Act grant programs implementation at national and local levels
Download and analyze the data for your own research projects.

I haven’t had much chance to dig into the data. As I do, I’ll write future posts on what I find. Also, there’s nothing better than crowd sourcing the look at large amounts of data. So, if you’ve found some data that’s interesting, let us know in the comments.

EMR Data Inaccuracies, EMR and Labs, and the Database of Healthcare

John — Mon, 14 May 2012 04:37:58 +0000

As you read this post, I’m probably on a red eye flight to attend Health 2.0 Boston. I’m really excited to attend Health 2.0 Boston. I think Matthew Holt is always interesting and so I hope I get a chance to interview him while I’m there. Plus, I think it’s large enough to bring out some important people, but not so large that you’re overwhelmed and can’t connect with those who attend.

Also, even if you’re just in Boston and not planning to attend Health 2.0 Boston, we’re going to be doing a tweetup on Tuesday evening. I call it the after party. I’m not sure where we’ll do it, but watch @ehrandhit on Twitter and I’ll tweet out the exact time and location for the tweetup. I look forward to seeing all my Boston Healthcare IT friends.

Now, without further ado, some interesting EMR tweets:

5 reasons #data inaccuracies occur in EMRs bradjust.us/J2qqLe #EMR #EHR

— Brad Justus (@Brad_Justus) May 13, 2012

The interesting part of the story linked above is that all of the inaccuracies could happen on paper as well.

RT @withyouDrWu Passive display of lab costs to clinic docs EMR ->less ordering cheaper tests #sgim2012 Horn @CostsofCare

— Vinny Arora (@FutureDocs) May 12, 2012

Reminds me of the announcement that said that physicians order more labs with EHR. I know we implemented the lab cost display in our EHR, and I’m sure that the cheaper tests were ordered, but that was certainly due to the type of clinic that I implemented the feature.

@ehrandhit Liked your thinking in #EHR – Database of Healthcare ow.ly/aHNAl CLOUD sees whole Internet as database 1/2 #HITsm

— CLOUDHealth (@CLOUDHealth) May 4, 2012

The idea of the internet as a database is very interesting. It’s probably too forward thinking to be really practical today, but we’ll definitely get there. It’s just a question of how quickly. We’re already seeing indications of this. It’s amazing what you can build in a weekend using “internet parts” through powerful APIs.

Note: This post has been a meaningful use free post.

Two Primary Obstacles to PHR Adoption per Epic

John — Fri, 11 May 2012 19:01:13 +0000

I recently happened upon the interoperability page on Epic’s website. Yes, I realize the irony of Epic and interoperability in the same sentence. In fact, that’s why I was so intrigued by what Epic had on their website about interoperability.

I’ll leave what they called the “physician-guided” interoperability using their Care Everywhere product for another post. In this post I just want to highlight their “freestanding Personal Health Record (PHR)” section. I was most intrigued by what Epic lists on that page as the “two primary obstacles to patient PHR adoption”:

Lucy [Epic's PHR] is free of the two primary obstacles to patient PHR adoption:
1. There are no advertisements on Lucy.
2. Epic will not sell patient data for secondary uses.

I find this really intriguing. Let’s look at each one individually.

First, I can’t say I’ve ever heard someone say that the reason they aren’t using an EHR is because of the advertisements. I’m sure there are a few out there that wouldn’t enjoy the ads and might not use a PHR because of them, but I believe they are few and far between. Plus, PHR use has been so low that most haven’t used a PHR enough to have seen ads. So, that’s not an obstacle. Not to mention, what PHR software has ads there now? As best to my knowledge Microsoft HealthVault, NoMoreClipboard and even the now defunct Google Health have never shown ads before.

Now to the second point about selling patient data for secondary uses. This could potentially be a bigger issue. There’s little doubt that there’s value in aggregate health data. A PHR is a legitimate way to collect that aggregate health data. Some certainly have some fear of their individualized health data being learned and so they don’t want to input their health data into a PHR. However, I believe there’s a larger majority that don’t care about this all that much. Sure, they want to make sure that the PHR uses proper security in their system. They also don’t want their individual data sold, but I expect a large user base doesn’t really care if aggregate healthcare data is sold in order for them to get a product that provides value to them.

In fact, this highlights the real problem with PHR software generally. To date, the PHR has offered little value to the patient. This is the primary obstacle to patient PHR adoption. I’ve hypothesized previously a couple things that could change that patient value equation: physician interaction in the PHR and paper work completion.

The real problem with PHR software is providing the patient value, not ads or sold patient data.

EHSD – EHR Hunt Stress Disorder

John — Thu, 10 May 2012 17:40:44 +0000

Dr. Gregg wrote an interesting post recently about what he called EHSD (EHR Hunt Stress Disorder). He does such a great job defining the funk, I’ll let his words speak for themselves.

Since I first broke the news about Allscripts’ sunsetting of my current EHR (Peak Practice) about a year and a half ago, I have developed a severe case of a newly defined malady: EHR Hunt Stress Disorder (EHSD). I am worn down, drug out, and generally pooped. I can’t figure anymore re: local host versus cloud versus disruptor / innovator versus corporate clout versus Quippe-able versus app-able versus templates versus NLP versus digital pens versus etc., etc., etc. I just can’t. I’m done.

I have seen a slew of systems — some great, some not so much. I’ve seen apps and clouds and cool tech. I’ve even had some had offers to work with some vendors. But, in trying to decide, I think I have run headlong into The Paradox of Choice wall. Too many options have led me to the paralyzingly dissatisfactional funk of EHSD. Can’t find that “just right” one.

I’ve seen this so many times. Sometimes it goes to outrageous extremes that you almost have to just laugh at the situation. I think the core of the problem is the 600+ EHR companies that are all vying for the physician’s attention. It’s an incredible challenge for physicians to sift through all the EHR noise.

One thing that I don’t think many people want to admit is that every practice could probably select a dozen or more different EHR software and be quite satisfied. Each of those dozen EHR software would have their own intricacies, annoyances and benefits, but they all would deliver some benefit to the practice. On the opposite end, there are at least some clinics who could select any of the 600 EHR vendors and have a terrible experience. Luckily, I believe this is the minority of clinics. Most clinics I know could find benefit from any 1 of a dozen EHR.

The challenge is that the dozen EHR that could provide benefit to a practice is different for every practice. The list of good EHR for a pediatric practice is different than for a OB/GYN or Family Practice Doc. The list of good EHR is different for a solo practice versus a large group practice or multi specialty group. The list of good EHR could be different for someone in California versus Ohio. You get the idea.

My best suggestion I first gave back in 2006 when I started blogging about EMR (The EHR term wasn’t in use back then). It is to quickly narrow your EHR selection to 5 EHR vendors. This will let you focus on 5 EHR and study them in depth. This doesn’t mean that you HAVE to select one of those 5 EHR. You can always add more later if you’re not satisfied with your first 5 EHR, but it gives you something manageable.

Just remember that the goal is to find an EHR that benefits your practice, not finding the perfect EHR. Setting reasonable expectations is a key to avoiding EHSD.

Cloud Computing Won’t Be the Death of Client Server EMR – Something Else Will Be

John — Wed, 09 May 2012 14:14:49 +0000

One of the all time favorite topics of discussion here at EMR and HIPAA is around SaaS EHR software versus client server EHR software. They each go by many other names and the technical among us might know the hard core technical difference between each, but most doctors don’t know and don’t care. SaaS EHR software is often called hosted EHR software or ASP EHR software or even Cloud Computing if you want to use a general term. Client Server EHR software is sometimes called in house EHR software or self hosted EHR software. I’m sure there are other names I missed.

Regardless of what you call it, many people (usually those from SaaS software vendors) believe that client server software will lose out to the cloud. It’s hard to argue with them since in almost every other industry cloud based software has won.

Here’s why I don’t think we’re going to spell the death of client server software for a long time to come. Client server is going to be here for a long time because of such wide adoption by so many doctors. Not to mention, many of the client server EHR systems are really large implementations that would be hard to displace. Plus, there are many doctors who don’t care about the mobile benefits of a SaaS based EHR software. Quite a few doctors want to only use their EHR software in their office.

Certainly there are others on a client server based EHR system which will want to access their EHR outside of their office. Unfortunately, instead of EHR replacement we’re likely to see a hybrid environment that supports client server and some sort of app environment come out of the various client server EHR vendors.

Sure, a lot of doctors will also use Citrix or other remote desktop environments and hate the user experience, but it will pacify them until the hybrid EHR environment is built. In fact, that hate towards the remote desktop environment on a mobile device will drive the development of this hybrid approach. The advantages of a client server environment with an app connection will keep the client server environment around for a while.

So, while many want to declare the death to client server, I’m not ready to do so. Sure, SaaS EHR software has its advantages, but client server software isn’t going to go down without a fight and they’re going to be around for a while since in many cases they hold the high ground.

Patient Relationship Management Taking on the Patient Portal and PHR

John — Tue, 08 May 2012 16:34:55 +0000

The other day I had the chance to get a demo of Avado‘s PRM (Patient Relationship Management) system from Dave Chase. I’d seen a lot of the writings of Dave Chase throughout the internet. He’s been really smart to go after a number of really high profile tech blogs to get some good exposure for Avado. This isn’t a good strategy for a lot of healthcare IT companies, but it can work really well for the right ones. Either way, I was fascinated by many of Dave Chase’s writings and so I knew it would be an interesting experience.

Needless to say, Dave Chase and Avado are looking at the physician patient relationship quite different from many others. At some point, I may do a full write up of the Avado service, but I think this slide that Dave Chase showed me summed up the comprehensive way that Avado looks at the physician patient relationship. Take a look at the comparison of Avado with a patient portal (I wish PHR was included in the chart as well):

I love companies that look at situations in a really comprehensive manner. Avado seems to be a company that does that. I think it’s still early to know if Avado will be able to execute on this comprehensive approach, but I think it’s a good starting point. Many who have looked at patient portals and PHR software in the past probably wondered why many of the things listed in the chart above weren’t features of the portal or PHR.

I must admit, my next idea for this list is to take it and see how the various PHR and portals handle each of the items on the list. Considering the new emphasis on the patient portal thanks to meaningful use stage 2, physicians might want to give a little extra thought into what the patient portal they adopt is able to do.

Comments Submitted on Stage 2: Is the Bar Being Raised Too High? – Meaningful Use Monday

Lynn — Mon, 07 May 2012 21:42:54 +0000

Lynn Scheps is Vice President, Government Affairs at EHR vendor SRSsoft. In this role, Lynn has been a Voice of Physicians and SRSsoft users in Washington during the formulation of the meaningful use criteria. Lynn is currently working to assist SRSsoft users interested in showing meaningful use and receiving the EHR incentive money. Check out Lynn’s previous Meaningful Use Monday posts.

The 60-day comment period on the Proposed Rule for Stage 2 Meaningful Use ends today. If the length and depth of the comments published so far are any indication, CMS will have a lot of reading and thinking to do between now and August, when the Final Rule is expected.

The tone of the comments is somewhat consistent—general support for the direction and spirit of the rule, but concern that the bar is being raised too high, too quickly. One fear is that if providers perceive the requirements to be unachievable or impractical, they could be discouraged from even trying to meet them.

These are some of the common themes that are already emerging:

Although MU Stage 2 was postponed to 2014, the timing is still very challenging. Several groups have already recommended a 90-day reporting period for the first year of MU Stage 2, which would provide for a phasing-in of the increased requirements, similar to MU Stage 1.
Meaningful Use Stage 2 is considerably more complex than Meaningful Use Stage 1, with the introduction of new measures and the addition of sub-components to Stage 1 measures. Many would require physicians and staff to implement new and more complex workflows.
The core and menu structure continues, but the menu options are fewer and would leave many providers with no real choices since several of the menu measures would not apply to their practices.
While increased patient engagement is recognized as an important goal, providers are expressing concern about having their incentives be dependent on actions by patients—actions over which they have no real control. For example, one proposed measure would require that 10% of patients access their information on the physician’s portal, and another that 10% of patients send a secure e-mail message to their physician.
Some measures could have significant cost implications for physicians—for example, there are often costs associated with developing the interfaces necessary to send data to registries and/or HIEs.
Clinical quality measure reporting, described in one set of comments as “daunting,” is eliciting detailed comments. Developing a reasonable set of requirements that are harmonized with other government programs will require a great deal of work.

More to come, as more comments become publicly available.

EMR as Medical Devices, Facebook Organ Donor Initiative, and Innovation at Big Companies

John — Mon, 07 May 2012 04:43:56 +0000

There was some interesting news this week in healthcare IT and EMR. Plus, there are some ongoing conversations that are still happening.

The following 3 tweets highlight this. It’s one of the things I love about Twitter is that you can discuss lots of interesting happenings and news along with discussing lots of important topics. Here are just a few of them that were talked about this week.

Absolutely. Look at the definition. > Should electronic medical records be considered medical devices? #EMR #HealthIT

— Wm T Oravecz (@WTOAssociates) May 4, 2012

I disagree. I think there are very few absolutes in this world, but I don’t EMR should be considered a medical device. There is more than enough government regulation going on with the EMR industry as is. I can’t imagine what benefit would be achieved with more government regulation.

Facebook Initiative Aims To Match Patients With Potential Organ Donorsow.ly/aDRn9 (1 step closer to FB EMR, I’m telling u!)…

— Jennifer Dennard (@SmyrnaGirl) May 2, 2012

This was big news and was a great illustration of the good that can be done by large companies like Facebook when it comes to healthcare. The real problem is that developers and entrepreneurs aren’t using the Facebook platform as much because they’ve killed it for the entrepreneur. Facebook is unlikely to do much on their own in the healthcare space other than these one off initiatives like this.

:) RT @danmunro Bingo! RT @HospitalEHR: Once the company creates an “innovation cnter” u know they’ve grown too big 2 really innovate #HITsm

— Jon Mertz (@jonmertz) May 4, 2012

The question in the #HITsm chat was which healthcare IT companies were innovating. My first answer was are there any big companies that are innovating? This was my follow up tweet about how “innovation centers.” Jennifer Dennard followed up with a question about whether hospital innovation centers counted. I can see an exception in some cases. Particularly when the hospital is squarely focused on research. Then, research can produce some innovative results and many things in healthcare cost so much money that it takes a large company to pay for the research.