A key premise: information should follow the patient, and artificial obstacles – technical, business related, bureaucratic – should not get in the way.  As a doctor, I have many times wanted access to data that I knew were buried in the computers or paper records of another health system across town.

As a medical transcriptionist, I’ve shared some of the same frustrations. I’ve typed discharge summaries that included paragraph after paragraph that does nothing more than summarize laboratory data over the course of the patient’s stay. Since medical transcriptionists are paid on volume, I shouldn’t complain – but c’mon, it’s boring and isn’t it already there somewhere? I’m not even talking about data exchange between facilities – this is a discharge summary, summarizing data that was available elsewhere in the same facility!

It’s always interesting to see what Dr. Blumenthal has to say about HITECH and I’ll be following his updates with interest.

This statement prompted me to write to the article author for a clarification:

Medical transcription is estimated to be a multi-billion dollar market and is expected to double in the next five years.

While I’d like to believe this is true, I have a difficult time believing it to be accurate. Medical transcription volumes have been reduced – and I anticipate they will continue to be reduced – as a result of EMRs and speech recognition. The author of the article kindly responded with a reference for the statement.

She referred me to an article at The Free Library: Healthcare automation driving growth in speech technology. In this article, the statement reads:

The market for speech recognition within healthcare will double in the next five years.

Now – that makes so much more sense! Because as we can see in the same article:

Using speech recognition with digital dictation systems, to dictate notes directly into EHRs, means that doctors can update information faster and with lower error rates.

The first article mentions medical transcription just briefly, with the notable misunderstanding of what is stated in the second article. The second article, however, seems to indicate that the author doesn’t have a clear understanding of how the process works. First of all, EHR and EMR are not interchangeable terms. A doctor dictating a note is more likely dictating it into an EMR, not an EHR. Second, if a provider is dictating notes directly into the EMR, then they aren’t dictating into a digital dictation system – they’re dictating it into the EMR, presumably (in light of the subject of the article) with speech recognition enabled to make the job easier/faster.

The market for speech recognition in healthcare doubling in the next 5 years doesn’t necessarily translate to a larger market share for medical transcription. In fact, according to the article:

Speech recognition is also being used for medical transcription, easing pressure on transcriptionists and allowing healthcare providers to save on staffing costs.

If the volume of dictation doubled, then there would be a requirement for MORE medical transcriptionists, and therefore no savings on staffing (or outsourcing) costs. But let’s suppose for a moment that the actual dictation volume does increase; the focus of the article is on speech recognition handling large volumes of the work – again, delivering a savings on staffing costs, presumably in reduction of transcription staff.

The article at the Free Library refers to an independent market analyst Datamonitor discusses speech recognition and its use in the medical industry for transcription and dictation (link only to the abstract at Scribd.com).Unfortunately, as much as I’d like to obtain it and sift through the very specific information it apparently contains, the Datamonitor report referred to is expensive and I have no real need for it that justifies the expense. We can see in the abstract, however, that it does report in future trends:

Speech recognition will become more embedded within document workflow and automation solutions.

Medical transcriptionists have been hearing about speech recognition for many, many years but only now is the full impact of the technology coming to bear in the industry. Technology rarely goes backward; if what we see today is becoming more and more useful in healthcare documentation, what we can expect to see in the future is better technology and a wider range of applications.

The point of this post is primarily to beat a drum I’ve been beating for many years; i.e., it’s important not to accept a statement as true or factual without checking the knowledge base of the author and the source of the statements. It would be a fallacy for the medical transcription industry to pick up and run with the statement “medical transcription… is expected to double in the next five years.”

Anyone who follows WM (owner of Sam’s Club) should have a pretty good idea of what happens when WM lines up a target. They are the single largest retailer in the world and the company has changed the face of retail America and its suppliers (a subject on which I’ll reserve further comment). Because it constitutes such a large portion of America’s economy, the company carries quite a big stick. I’ve read stories of vendors’ dealings with buyers in the great halls of Wal-Mart in Bentonville, Arkansas. What Wal-Mart buyers say they require, the vendor WILL deliver – it’s simply too large a marketplace to ignore or flip off.

And let’s not forget Dell, which is part of the deal and will be supplying the hardware that will be running this show. The deal claims that “cost and complexity” of physician adaptation of an EMR will be mitigated by the Sam’s Club offering.

The blogosphere that follows healthcare technology exploded with its opinions about this deal.

An Odd Couple with Good Intentions at the EMR Software Advice blog is a good description of this marketing marriage.

Furthermore, we do see some very real sales and services challenges arising from this partnership. Simply put: sophisticated, $25,000 EMR systems don’t sell themselves. Get a Wal-Mart “greeter” involved and things could get ugly. Wal-Mart has already stumbled a bit trying to support the relatively complex sale of iPhones. EMRs are a far more complex sale. My mind goes to the horribly awkward image of a brilliant, yet intolerant, cardiologist interrogating a greeter about eCW functionality. The mismatch of intellect and clinical expertise could be incendiary.

Topping off the accuracy of the above statement, WM and eCW haven’t been terribly forthcoming about what price breaks they’re offering or what additional value the buyer gets by going through the Sam’s Club offering.

(Just for kicks and grins, I went to the Sam’s Club web site to see if this had been added as one of the services.  So far, it’s not. But I did get a giggle when I pictured “electronic medical records” listed as a service with credit card processing, web site services, printing and shipping, and commercial insurance. I mean, really – isn’t it just a TAD more complex than that??)

Putting aside my sense of humor and cynicism, I’d have to point out how happy I’ve been with  business services through Costco. I’ve used their business service for payroll and voice mail services, and their personal service for auto purchase. Basically, it’s a matter of using the required format for letting the vendor know you came to them through Costco so you can get the discount. Once you’ve done that, you’re in the hands of the vendor and Costco doesn’t get involved – or I’ve never had a reason to try and involve Costco.

Back in my cynic mode… if the Sam’sClub/eCW deal is going to accomplish what the press release claims, that’s not the way the transaction is going to happen.

In reading the press release, it sounds to me like Sam’s Club plans on facilitating sales and implementation, not just introducing the parties and standing back – which is the way the transactions for services at places like Costco and Wal-Mart currently are handled.

“Cost and complexity have been the primary barriers to EMR adoption,” said James Coffin, vice president of Dell’s Healthcare and Life Sciences business. “Partnering with eClinicalWorks and Sam’s Club, we are addressing both by providing an EMR solution that is easy to purchase, easy to implement and easy to manage so that healthcare providers spend less time on administration and more time serving patients.”

Unless Sam’s Club has facilitators, nothing in this partnership makes any of these processes easier. And if there is a third party injected to facilitate, it would seem to me the cost would go up, not down. Perhaps Sam’s Club is requiring Dell and eCW to step up implementation service? Without more information from any of the parties involved, it’s difficult to say.

Further in my cynicism… I frequently have people contact me, wanting to sell me services to find clients. Here’s the thing, however: my client base isn’t difficult to find. By the same token, eCW’s client base should be pretty easy to find. I’m not quite sure what they get from partnering with WM when it’s so easy to identify potential customers and reach them in the appropriate place for selling an EMR (i.e., their office) and when they’re in the frame of mind to buy what’s being sold (i.e., at work). I’m having a difficult time picturing  someone at a practice meeting snapping their fingers and saying, “EMR – hey, let’s check out Sam’s Club!” Or a doctor detouring from the snack aisle to go check out what Sam’s Club has in the way of EMRs for the office. If you can’t sell an EMR directly to an easily identified client, I’m not quite sure what Sam’s Club is going to do for your product sales.

And what does this say for the current implementation process? It sucks? I had a transcription client buy the eCW EMR and they practically held their hand throughout the entire process, carefully easing the digital recorders out and the laptop computers in. Maybe they don’t provide that level of support to all customers, but if they can’t do it without Sam’s Club, what’s to say they can do it with Sam’s Club?

Chilmark Research also had a bit to say about the deal. They contacted eCW for more information. In a February 11, 2009 post at their blog, they say eClinicalWorks Tight-lipped on Wal-Mart Deal. If I read this blog entry, as well as the NYT article linked there, correctly, Wal-Mart plans on utilizing the EMR in their in-store clinics, which are operated in in partnership with Revolution Health. (Wasn’t Wal-Mart throwing its hat into the home-grown EHR market a couple years ago?) Apparently, part of the plan is to provide eCW with a ready market, while getting a discount for the Wal-Mart branded clinics.

I also found this blog article interesting: The Wal-Mart of EMR.

eClinicalWorks beat out a host of larger EMR players. Why? I’ve heard competitors refer to eClinicalWorks as “the Wal-Mart of EMRs.” This is a compliment, given the company’s success in the small and medium practice group market. A regular Best in KLAS favorite, eClinicalWorks is cheap, easy to use, built natively on the Web, and strong on functionality without laboring under lots of bells and whistles. “Value,” as Wal-Mart shoppers would say.

And what makes it most interesting is the date on the post – April 25, 2006! Who knows – maybe this blog was the catalyst for the deal!

Other blogs on the Wal-Mart (Sam’sClub)/eClinicalWorks EMR:

• Wal-Mart, eClinicalWorks team up to sell e-health systems
• Wal-Mart, eClinicalWorks Deal Exposes Need For EMR Price Transparency
• Walmart and eClinicalWorks: An Odd Couple?
• eClinicalWorks EHR and Wal-Mart – More Details and Information
• WalMart eClinicalWorks Dell Not Quite All There

Richard Smith is an unpaid member of the board of Patients Know Best and a true believer that the web can ultimately transform health care as it is transforming so much else.

This is a UK author but the sentiment behind it applies worldwide and is especially timely in the US, with the Obama administration including a hefty boost to health IT and EHRs in the stimulus plan.

I spend half my life online. Most of my work is done online. I shop, manage my finances, and do my taxes online. My web footprint is huge. So why have I never asked for access to the most intimate details about me that are kept on a computer about a mile from here?

In his presentation at TEPR, James Mault, MD (Director, New Products and Business Development, Microsoft Health Solutions Group) stated that security and privacy issues aside, most of the information is already online – but the patient doesn’t have the benefit of accessing it or making it available to other providers.

With the EMIS system, which is used by 60% of GPs, it is easy, and cost free, to give patients access to their records. But only 40 practices in the country have done it so far—we are very much at the beginning of this revolution.

Noting that the UK’s nationalized system puts health IT on a different level than the US, one of the points driven home again and again at the TEPR conference was that the adoption of EMRs and EHRs would be market driven. In other words, when physicians see a monetary reason for using an EMR (higher levels of reimbursement, incentives from third-party payers, the ability to see more patients) and have more patients demanding electronic access to their records, they will be more inclined to join this revolution. Likewise, software vendors will react to the demand.

A personal health record is one that the patient rather than the doctor controls, and this is surely where we must be headed. There is published evidence showing that personal health records can produce many benefits, are particularly valuable for patients with chronic conditions, and improve compliance and care. Interaction is better than simply access, and “coauthorship” between patients and doctors creates accuracy and concordance.

In a TEPR keynote, Dave deBronkart and Danny Sands, MD gave a presentation on how Dave deBronkart used free Web 2.0 resources to be a proactive patient after he was diagnosed with cancer (Healthcare IT news article). Dave’s contact with Dr. Sands was through the Beth Israel Deaconess patient portal (PatientSite), where patients can make appointments and communicate with their physicians. Paraphrasing Dr. Sands’ comments on this system:

In what other profession do you set a date and a time for a meeting without also setting an agenda? And yet, this is the norm in medicine. Doctors have no idea why the patient wants to see them until they are in the office. With PatientSite, the patient lets the doctor know why they want to be seen. Tests can be ordered in advance so that everyone is prepared for the meeting by the time the patient is seen in the office.

It makes so much sense, it’s frightening, isn’t it? It’s a simple concept, used in businesses around the world on a daily basis – but the medical profession seems to just be starting to grasp the value.

I am reminded of an appointment I had with a physician in 2007, where I drove to UCLA (30 minutes to go 15 miles, on a good day), parked ($8), waited (20 minutes), was asked to undress (unnecessarily), had blood drawn (again – and unnecessary – but I couldn’t convince the office staff of this) – all to get the results of a blood test that had been drawn 2 weeks previously, only to be told the results weren’t back from the lab yet. I wasted 2 hours of my time, spent money on gas and parking, which online access (or a simple phone call!) would have made completely unnecessary. And UCLA has an EMR – but as a patient, I have no access to it. The UCLA surgeon who referred me to this doctor had access to the records and the test results; the physician I went to for a second opinion had access to them, as well. Why didn’t I?

How would your physician react if you sent an agenda for your next appointment? Or demanded electronic access to your records on an ongoing and updated basis?

The pressure for change must come from the market. Patients need to see the value of having access to their records, they need to pressure the medical community to provide it and they need to pressure the third-party payors to provide incentives for the medical providers for using EMRs and giving patients access to their records.

This is the last conference, at least under the management of the Medical Records Institute.

Which is an interesting development, in my opinion.

There are good sessions at the conference but registration has been dwindling. What I’m hearing from the people I talk to – current and past attendees, exhibitors and speakers – is that the conference isn’t seen as being exactly leading edge. One correspondent indicated to me that the conference “has a Health 1.0 feel” to it.

Which is validated somewhat when you look at MRI leadership’s participation – or lack thereof – in social media. There is a LinkedIn group for conference attendees, but at present it has only 8 members and a day after applying to join the group, I’m still waiting to be approved. In addition, the group wasn’t initiated by leadership at MRI, but by one of the other attendees. And as I go through some of the discussions in the various groups I belong to, I’m seeing questions that could – and should – be answered by someone at MRI if their goal is to be leaders in healthcare IT, but they have a disturbing lack of presence at LinkedIn.

And at Facebook. And on Twitter. In fact, Twitter user (and blogger) ePatientDave asked those present at a keynote address he participated in how many people use Twitter and there were very few of us who raised hands. There was a very small tweetup at the gala reception later in the evening!

And yet – this is the conference that’s supposed to be all about the leading technologies in healthcare. Let’s face it – Web 2.0 is playing a large role in that technology.

It will be interesting to see if TEPR (or something like it) is reinvented or if this is the last hurrah of what used to be a really great conference.

They may be leading the e-healthcare revolution but they aren’t even in the cutting edge of social networking to promote their leadership and ideals. And what does that say about their leadership? Am I the only one who thinks it affects their credibility as a leading company when they aren’t demonstrating an ability and willingness to participate in cutting edge social networking to promote their ideas and philosophy?

I think they’re missing a great opportunity. For one thing, they have an international audience and the social networks are international. For another, social networking is probably the easiest, least expensive way of promoting their organization and its purpose.

Do you consider yourself on the cutting edge of all things tech? Are you engaging in social networking to create new connections and promote your business and services?

We have offered this service to businesses that knew about it for the last couple of years but never rolled it out on a more commercial basis. The instructions have been updated and everyone likes the service so much, we’re going to make it available.

FileDocs is powered by Novell iFolder server using the iFolder3 client application. This is secure file sharing and files are encrypted on the server. You can install the client on any computer for automated sync and you can access files via a browser. Browser access does not support automated sync or multiple file upload/download.

This system is an excellent alternative for small transcription services and individuals who offer transcription to physicians/groups using digital recorders. It’s incredibly easy and reliable, making it possible for even the most technically challenged to use it without any problems.

You can find pricing and information on the FileDocs page at this site. Please feel free to use the contact form

The original intent of the site was speech recognition products and technologies and we’ll stay focused on that, but in a more bloggy way.  TalkDocs’ redirection will be discussions about speech recognition and automated technologies for medical professionals.

Please feel free to participate.