If you’re in the DC area, you might be interested in attending FedSources InFocus Event on Healthcare Technology. FedSources is a company that provides market intelligence around government contracting and opportunities. I’ll probably be attending so if you’re planning on attending let me know and we can catch up at the event.

The event is being held at the  McLean Hilton in Tysons Corner, VA on Thursday January 28 at 5:00p.

I love these kinds of stories. Last week Gizmodo posted In Early Tests, $99 Wii Balance Board Outperforms $17,885 Medical Rig which was initially reported in New Scientist’s Wii board helps physios strike a balance after strokes. Basically, the story revolves around a paper published by Ross Clark in which Clark’s team compared a $99 Wii Balance Board (used in gaming and exercising while connected to the Wii console) to an almost $18,000 force platform. The paper confirms that the $100 device is clinically comparable to the $18k device. As reported by New Scientist, Clark says:

The low price of the Wii kit is now seeing it used to assess rehabilitation after stroke, traumatic brain injuries and to examine standing balance in children who were born pre-term.

Kudos to Clark. Not kudos that a $100 device can do the work of an $18k device (after all, medical devices are not expensive because they’re necessarily hard or costly to make but because they don’t sell in high volumes). But, Kudos because Clark is thinking outside the box — the technology in our cell phones and calculators today is more sophisticated than many medical devices and it’s great to see researchers doing evidence-based reporting to show clinical “efficacy” of these devices.

Scrambling to meet the end of year deadline set forth in the ARRA HITECH statute, HHS hits the mark with its release of the interim final 45 CFR Part 170, Initial Set of Standards, Implementation Specifications, and Certification Criteria for Electronic Health Record Technology. I will have more to say about the contents over the coming days and weeks as I review it.

My initial reaction is that the content is pretty good — it’s not very precise nor is it actually independently verifiable (yet) but the folks at HHS have done well. The meat of the materials for most EHR firms starts on page 51 with the actual meaningful use and certification requirements map. In yesterday’s press conference Dr. Blumenthal confirmed that no certification body requirements language is yet present and there are no certifying bodies that have been authorized to perform certifications against this criteria. All of that is “coming soon” he said. So, while the interim rules are out, my caution is that you should still not be bullied by EMR vendors because nobody can say that they are HHS certified yet.

HHS Interim Final 45 CFR Part 170, Health Information Technology: Initial Set of Standards, Implementation …

I’ve been hearing a lot of stories these days about EMR companies telling potential physician customers that they need to buy a sophisticated or “full blown” EMR right now in order to get any stimulus funds. Some of my readers have asked whether this is true or not so let me set the record straight.

Yes, it’s true that the ARRA HITECH Act clearly states (in section 4101, page 353) that the government shall provide “incentives for adoption and meaningful use of certified EHR technology.” Specifically, the language in the bill (page 353) says:

Subject to the succeeding subparagraphs of this paragraph, with respect to covered professional services furnished by an eligible professional during a payment year (as defined in subparagraph (E)), if the eligible professional is a meaningful EHR user (as determined under paragraph (2)) for the EHR reporting period with respect to such year, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)), from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 an amount equal to 75 percent of the Secretary’s estimate (based on claims submitted not later than 2 months after the end of the payment year) of the allowed charges under this part for all such covered professional services furnished by the eligible professional during such year.

Later, “certified EHR technology” is further define on page 356 as:

MEANINGFUL USE OF CERTIFIED EHR TECHNOLOGY.—The eligible professional demonstrates to the satisfaction of the Secretary, in accordance with subparagraph (C)(i), that during such period the professional is using certified EHR technology in a meaningful manner, which shall include the use of electronic prescribing as determined to be appropriate by the Secretary.

If this sounds like legalese and mumbo jumbo, I agree. And, if it sounds like it’s murky and unclear, well, it is and it’s meant to be.

When a vendor comes to you and tells you that you need to purchase something because the stimulus bill is telling you to, ask them to show you the language in the bill that indicates that. If they can’t point to a page in the bill or a Medicare regulation, it’s probably a fear tactic and you should be very wary.

The only thing that we know for sure right now is what is in the bill — that certified EHR technology is required for incentive payments. However, nobody knows how much actual money will be incentivized to a particular physician, nobody knows what the final certification requirements will be, nobody knows exactly which certifications will guarantee payments, etc. The reason none of this is known is that the Secretary of HHS and the head of CMS (Medicare) havent written the rules that they are required to write. It will be many more months before the hundreds of pages of regulations necessary to enact many provisions of the bill will be written and approved.

Anyone who says they know what will be in the federal rules is either misleading you or is delusional .

The unknowns are greater than the knowns, even today, almost a year after ARRA was passed. If the only reason you’re buying an EMR is to get incentive money then you should wait until at least this Summer when things are clearer (but you should prepare yourself using some guidance I provided earlier).

If, however, you’re buying electronic health records management technology to improve your business or improve clinical care with a clear payback period and ROI then it shouldn’t matter whether you get the incentives or not — the savings to your business should be enough to convince you; if the savings aren’t there, then even the incentives shouldn’t change your mind because it’s not likely that the government can provide enough money to compensate you for the inevtiable operations hit you’ll take with a full-fledged EMR.

My simple advice is this: treat the incentive payments as a bonus — if you get it, great. If not, it shouldn’t kill you. Don’t jump into any technology promises that can only be realized if the government does it’s job. You’ve been there before, I’m sure.

Massachusetts Medical Law Report’s Social networking 101 for physicians is a great summary for physicians who are looking to get into social networking or have already been participating for some time.

It’s got some great tips that sound obvious but should be heeded carefully:

• Be mindful of patient confidentiality.
• Remember that your patients are not your ‘friends.’
• Monitor your web presence regularly.
• Take advice from online doctors’ forums with a grain of salt.
• Be aware that you’re never truly anonymous on the web.

It may seem like the article is scaring you into not using social media to improve your medical practice or is providing techniques that limits social media’s effectiveness but in actually it’s just common sense advice for one of the world’s most litigated professions. It’s well worth reading.

Thanks to Engadget and KevinMD for the pointers to this article.

The Markle Foundation has been giving some very reasonable advice on the use of IT and technology in general for the healthcare industry. Their most important advice, if heeded by lawmakers, would put to effective use the billions of dollars that have been earmarked for healthcare IT in the ARRA stimulus bill.

I loved what they said in their letter to Frizzera (CMS), Blumenthal (ONCHIT), and Orszag (OMB).

On page 3:

In setting metrics, HHS should resist the temptation to impose too many prescriptive technology requirements. The most constructive part of the rule will define what needs to be achieved as opposed to precisely how systems must behave to achieve it….The requirements should not require a narrow process or deployment of a particular tool. Rather, technology and care redesign innovations should be encouraged to engage consumers more fully in planning and managing their care through a variety of approaches.

On page 4:

The approach to standards must enable a wide array of providers with varying levels of IT adoption and support, from sophisticated integrated delivery systems to the physician in solo practice, to achieve the goals of Meaningful Use. Technology or standards requirements that are unnecessarily complex, or that fail to take into account the diverse needs of a wide spectrum of health care providers, can have the unintended consequence of narrowing participation. Care must be taken to avoid stifling alternatives or innovations that would otherwise propel more widespread adoption of health IT to improve health care quality and costeffectiveness.

These direct statements take into account the mistakes made in the past by folks (like CCHIT and others) who believe that features and functions in software create better outcomes. We all know that people and process which the right selection of a wide variety of technologies (and no specific product or vendor) create better outcomes.

It’s great to see that influential voices like Markle are making the arguments clearly and in an easy to understand manner. Those of us in the healthcare IT sector of the industry should use materials from Markle to make our cases as well. Everyone is focused and listening and now is the time to make sure we don’t repeat the mistakes of the past and push specific vendors and technologies or products into legislation or rule-making.

In an associated document entitled “Demonstrating Meaningful Use of Health IT for 2011 and Beyond” Markle advises the following foundational principles:

• Prioritize “measures that matter” for health improvement—measures that demonstrate improved health outcomes and greater cost-effectiveness.
• Be operationally feasible for 2011 and beyond for a broad range of providers, vendors and the Centers for Medicare and Medicaid Services (CMS).
• Leverage existing quality reporting efforts if they meet these criteria and work in alignment toward meaningful use goals.
• Implement processes that will proactively improve data quality and data integrity over time.
• Minimize unnecessary burden and cost by enabling reporting of “measures that matter” as a byproduct of using qualified health information technology. Providers should be able to easily submit data to demonstrate meaningful use without significant additional overhead and effort.
• Give providers timely access to the quality and cost information they need to improve care. Demonstrating meaningful use should help providers and patients improve health and health outcomes, and not just be a time-consuming administrative data reporting or documentation exercise.

Later on page 7 they make a great point (the emphasis on compliance exercise is mine):

Systems must be able to support providers’ needs for information to meet meaningful use goals. The underlying objective is to put useful information into the hands of providers and patients to improve care, and not to create a compliance exercise.

I’m hoping that Dr. Blumenthal will give Markle’s recommendations due attention.

Given my recent postings on how to ease into technology before jumping head-first into EMRs, many readers wrote back asking additional questions about how else they should get ready for EMRs. To make sure readers get the best software selection advice, I reached out to Sheldon Needle, who is president and founder of CTSGuides.com, publishers of software evaluation materials. They have a free Medical Software Selection kit for indepth reviews of leading EMR, scheduling, and billing software, performance ratings for over 800 features, and a template to plan and manage your software demos. Sheldon’s been helping companies buy software for many years and his advice on what to do even before you choose your software is priceless. Here’s what Sheldon had to say:

The reason to purchase EMR or any medical software is to make your practice work better for you, your staff, and your patients. Keeping this at the forefront of your medical software decision will put the brakes on foolish purchases that may offer glitter but don’t offer your practice enhanced functionality and don’t offer your patients improvements in the quality of care they receive.

Though there is no need to leap  blindly into an EMR no matter how many incentives are offered to you,  you can be quite sure than an EMR is in your future. There are certainly preparatory steps to take for a transition to EMR. Even if you are a year or two away from making your EMR / EHR software buying decision, there are many things you can do now to make the eventual medical software implementation easier. Though the purchase should not be rushed, the transition is going to happen, so get ready now.

As the marines say, “semper preparatus” always  be prepared.  Here are ways to begin your implementation even before you know which EMR system you will choose:

1. Make sure that everyone in your organization is extremely comfortable with using his or her computer. Not just your desktop computer, but your laptop and tablet PC need to be easily managed by all hands on board.  Support staff – administrators, receptionists, sonographers, and x-ray technicians, and nurses who already use many electronic instruments for tests and for administrative tasks  – are perfectly comfortable with using different types of computers, but many doctors are not.  If your physicians  will not be comfortable using your EMR and its associated technology, the war is lost before it has begun. Which brings us to the next readiness step:
2. Your medical practice requires what the marketing people call “buy-in”!  Everyone has to be on board with the plan to move to an EMR. If they are not, discuss their reasons for opposing the move.   Often, it is because of lack of comfort with the technology.  Some vendors will offer preliminary seminars on EMR in order to interest prospective clients.  Offer one to your employees, so that they can see the types of change their use of EMR will bring.
3. Talk to colleagues who have already made the move to EMR or other medical software. Find out which features they like, and which they don’t. Find out how difficult it is to maintain HIPAA compliance with different systems. Find out which vendors offered good support and training.
4. Read medical software reviews. There is a tremendous amount of valuable software information available at no cost to you online.   You can learn about different features, and think about how they might be used in your practice.
5. Consider which parts of your practice are most amenable to going electronic and which are least amenable. EMR and medical software is not an all or nothing proposition.  It could be that your practice should not be moving all of its functions to electronic media just yet. And it almost surely should not be moving all modular functions at once. Discuss this question with key people in your organization: your medical billing specialists, your nurses, and your doctors.
6. Consider whether your might want an in-house client-server solution, or a web based Software-As-A-Service solution that you lease and log into from any location. EMR and medical software solutions like this are becoming more feasible and are often more affordable than having your own in-house server and having to manage security and backup of your data.
   
   
7. If your medical billing is not yet electronic, this may well be the way to begin your transition to medical software. Your medical billing must become electronic almost before anything else. Medical billing presents the quickest ROI of all EMR modules, because it allows for quick turnaround on claims denials, code lookup, and an opportunity to be more easily HIPAA compliant than your paper files allow.  Prepare your staff and data to migrate to a medical billing module as quickly as possible. Otherwise,  because of reporting requirements and claims processing alone, your bottom line will be compromised.
8. Identify an in-house leader and liaison. If you already have an IT person on board, and he has the people skills as well as the technical skills to act as a liaison when you are planning your purchase, ask her to read up different EMR configurations, on implementation schemes, and EMR priorities in relation to your practice. If you are a large enough practice, identify a physician who you think can be the physician liaison for the implementation.  Give these people time and space to do some  research – talking to colleagues, attending free or low cost seminars, reading, etc.
9. Make use of your scanner today! If you haven’t already, buy a good quality scanner that is easy to use, and make sure everyone know how to use it. Start scanning your newer patient documents now so that when you actually get to implementation stage, you do not have to re-invent the wheel scan every piece of material within  your archives and records.

These preparatory steps will make your move to an EMR simpler, and should give you some insight into criteria for choosing the right EMR.  Never buy into an all-or-nothing strategy for implementation. You cannot expect to change the entire workflow of your practice when you implement an EMR – and you do not want to.  You need to follow the demands of your practice, when reasonable.  And most of all, you need to work with your staff as a teamso that when you find the right EMR you can begin with a full complement of invested, able people who want your investment of money, time and effort to make sense.

This week The New York Times reported in Little Benefit Seen, So Far, in Electronic Patient Records that:

The nation is set to begin an ambitious program, backed by $19 billion in government incentives, to accelerate the adoption of computerized patient records in doctors’ offices and hospitals, replacing ink and paper. There is wide agreement that the conversion will bring better care and lower costs, saving the American health care system up to $100 billion a year by some estimates.

But a new study comparing 3,000 hospitals at various stages in the adoption of computerized health records has found little difference in the cost and quality of care.

“The way electronic medical records are used now has not yet had a real impact on the quality or cost of health care,” said Dr. Ashish K. Jha, an assistant professor at the Harvard School of Public Health, who led the research project.

The emphasis above is mine and as a technology strategist and evidence-based engineering proponent I was ecstatic to see that studies were being cited as opposed to just conjecture. The two things we’re most interested in from computerized records are improving quality of care and reducing costs. However, since we don’t track very good metrics and measures on either of the facets we’re looking to improve, it’s almost impossible to know how the simple act of creating electronic records will get us what we desire.

The EMR debate (if there is such a thing) reminds me of the CRM (customer relationship management) and SFA (sales force automation) debate in the non-healthcare sector of our economy. SFA is to other firms what EMRs are to clinical firms — CRMs help manage customer data longitudinally like EMRs help manage patient data. However, just like EMRs in medical firms haven’t proven to provide promised benefits, CRMs haven’t lived up to their promise either.

If you’re a CIO or executive and you’re trying to figure out what to do with EMRs in general take a look at the SFA space and see how well CRMs are doing across the industry. Lessons from the implementation of CRMs should help us figure out how to gain advantage from deployments of EMRs.

UPDATE: Dr. Glenn Laffel thinks the Harvard Study got it wrong. There are lots of good comments with an excellent discussion going on at The Health Care Blog about this topic.

SoftwareAdvice.com recently posed the following questions to its readers in a survey format: “Are more doctors buying electronic medical records than before? Or, has the Stimulus bill only brought out the tire kickers?“. The results of the survey are available here; while the survey wasn’t scientific and it didn’t have enough participants to draw wide scale conclusions, the results do imply a general feeling of positive momentum towards the purchase and implementation of EMRs.

As an experienced healthcare IT professional I am very happy to see that people are looking towards EMRs and automation to improve healthcare staff productivity. However, I’d like to urge a bit of caution and be sure that buyers don’t jump into the market for the wrong reason. My rule about automation and insertion of software in any workflow process is simple: if you can’t repeat it, don’t bother automating it.

How to choose the right software and technology

For most potential users of EMRs, EHRs, and other “complex” workflow automation tools you should ease into the technology. What that means is that before you install any new technology, ensure that first and foremost it does no harm. All technology takes time to implement and get significant improvements; what’s important is that while you’re working towards improvement you don’t harm your business in the process. Technology should first and foremost not make a practice, department, or hospital worse off than it was before the technology was introduced. Then, it should start improving or “healing”.

Second, focus on interoperability and best of breed. Our desired tendency is to go for “all inclusive” or “complete solutions” but healthcare is too complex for any single vendor or package to do everything. By focusing on best of breed and interoperability you can grow at your pace and choose solutions that you really need versus those that the vendors think you need.

Third, Ask the right questions of your vendors and staff when they’re selecting any new technology. Don’t worry about features, functions, and technology. Worry more about your business (which is healthcare and patient happiness) by asking questions like this:

• Will my patient be more satisfied because I’m using the system?
• Will the outcome of care be improved because I’m using the system?
• Can I spend more time on my patient’s care versus documenting the encounter?
• How many more patients per day will I be able to see because of the system?
• Can I go home earlier because the system helps me finish my work faster?
• How many fewer lawsuits will be filed because I used the system?

Fourth, make sure the technology fits with your desired outcomes (not tasks). Almost any software will improve some aspects of your business — but, the question is will the software improve the aspects you care the most about? When asking technical questions, start with some of these:

• How can I easily transmit my patient’s medical records in a safe and secure manner without spending all day making copies?
• How many more lawsuits will I win because I used the system?
• How will the system be able to increase my patient population or help me market my services better?
• How much faster can I get paid for my services after I’m using the system?
• Can I get secure access to my data while I’m away from home or the office?

Fifth, be sure it can handle all the different kinds of data you have. Most vendors or technology providers focus you on what kinds of data they can manage. But, any reasonable office deals with all the following kinds of data and you need to make sure your selection can manage it:

• Structured data (fully coded ICD, CPT, etc)
• Semi-structured data (machine understandable but with keywords and such)
• Unstructured data (natural language)
• Images
• Faxes
• Audio
• Video
• Chat logs, e-mail logs
• probably many others

Most software systems handle structured data quite well. In fact, EMRs are an excellent way to capture structured data but in my experience structured data makes up only a small fraction of healthcare data. Semi-structured data and completely unstructured data along with faxes make up a big portion of data and medical images make up an even larger portion of the healthcare data pie. Video and email, chat, and other upcoming technologies will be taking up larger portions of database space as well.

When you’re choosing a technology, be sure to look at the kind of data you’re capturing regularly and ensure that the vendor you choose and the deployment model you pick are geared towards the data you create rather than the kind of data the vendor can store. Again, almost all vendors are great at structured data but there are very few that are good a non-structured data, faxes, images, and similar information. When looking at “cloud providers” (online software) make sure that the larger data you capture can be fit through your network pipes.

An EMR isn’t necessarily the first way to automate

While most people who are new to healthcare IT or looking to jump in quickly always point to EMRs as the most important application, there are actually many different healthcare IT applications that make up the “industry” as a whole. When you’re dealing with healthcare IT, EMRs might be a good entry point for some folks but it’s actually more likely that EMRs aren’t your first place to start your automation journey. These are some other techniques I’ve used to kick off automation before jumping into full-fledged EMRs:

• E-mail (beware of HIPAA, though) — internal office messaging and email is a great place to start. If you haven’t started your office automation journey here you should.
• E-Prescribing — e-prescribing is a great place to start your automation journey because it’s a fast way to realize how much slower the digital process is in capturing clinical data. If e-prescribing alone makes you slower in your job, EMRs will likely affect you even more. If you’re productive with e-prescribing then EMRs in general will make you more productive too.
• Office Online and Google Apps (scheduling, document sharing) — Google and Microsoft have some very nice online tools for managing contacts (your patients are contacts), scheduling (appointments), dirt simple document management, and getting everyone in the office “on the same page”. Before you jump into full-fledged EMRs see if these basic free tools can do the job for you.
• Clinical groupware — this is a new category of software that allows you to collaborate with colleagues on your most time-consuming or most-needy patients and leave the remainder of them as-is. By automating what’s taking the most of your time you don’t worry about the majority of patients who aren’t.
• Patient registry and CCR bulletin board — if you’re just looking for basic patient population management and not detailed office automation then patient registries and CCR databases are a great start. These don’t help with workflow but they do manage patient summaries.
• Document imaging — scanning and storing your paper documents is something that affects everyone; all scanners come with some basic imaging software that you can use for free. Once you’re good at scanning and paper digitization you can move to “medical grade” document managements that can improve productivity even more.
• Clinical content repository (CMS) — open source systems like Drupal and Joomla do a great job of content management and they can be adapted to do clinical content management.
• Electronic lab reporting — if labs are taking up most of your time, you can automate that pretty easily with web-based lab reporting systems.
• Electronic transcription — if clinical note taking is taking most of your time, you can automate that by using electronic transcribing.
• Speech recognition — another “point solution” to helping with capturing clinical notes; you can get a system up and running for under $250.

If you’re a physician or responsible for managing an office or an enterprise the government and vendors of technology solutions will be pressuring you to “jump on the bandwagon”. Tell them that Shahid said you shouldn’t don’t drink the Kool-Aid and that it’s ok to be afraid of bloated EMRs and ease into medical technology.

Kevin Clifford and I were chatting about his experiences in taking a Michigan-area free clinic live on an open source EMR and I was very interested to share it with others. Kevin said he volunteered at the free clinic because he wanted to serve his community and said that there are many other such free clinics in need of IT improvements in Michigan and elsewhere. I asked him to write a quick summary of what he did and how it worked. What Kevin is doing is an excellent example for other IT firms looking to break into healthcare IT — use open source and other free tools to help your local community clinics and physician offices. Here’s what Kevin had to say about his experience:

I recently started volunteering at a free health clinic in Pontiac Michigan. The clinic has 30 doctors and dentists that volunteer their time seeing 500 to 600 uninsured patients per month. The clinic has an in-house pharmacy and three full time employees. I have an I/T background so my original intent was to help the clinic with any technical issues they may have such as setting up their website and network. Once I started working at the clinic I noticed they were having trouble keeping track of patient files and were making all appointments on paper. In addition they had to go through all their files monthly in order to track specific patient categories and follow-up on missing information.

I suggested to the clinic that they try OpenEMR, an open source EMR system. They liked the demo I showed them and I started the installation. I installed the OpenEMR appliance which runs on the VMware virtual server, the appliance allowed me to run the LAMP version of OpenEMR on a windows machine. I then configured the appliance so it would use a static IP address.

Once the program was up and running I changed the layouts and added fields for specific information that the clinic needed to collect. The most time consuming and labor intensive part of the install was in transferring all the patient records over to the program. Through the PHPMyAdmin part of the tool I was able to create the SQL queries that allowed the clinic to run the specialized reports that they needed. Our plan at the clinic is to continue exploring the capabilities of OpenEMR in order to improve the clinics efficiency even more.

The program has allowed the clinic to:

• Schedule patients and doctors electronically
• Manage patient encounters
• Save time by running reports on patient data

Due to the current economic environment the number of patients seen at the clinic has risen dramatically over the last year and there is currently a waiting list. There are a number of similar clinics located throughout the country that could improve efficiencies by installing an open source EMR system. I would like to expand the service on OpenEMR implementations to free medical clinics and am looking for thoughts and advice from the community.

If you have any suggestions or are interested in working with me on this endeavor please provide feedback here on Shahid’s site via comments if you want to speak publicly or if you prefer private communication you can contact me at kclifford@gmail.com.