EMRs, what doctors really want.

I’m in the EMR business. Although I’m not in sales, I do perform sales demos (more technical than sales) and work directly with doctors and clinical staff to design and implement customizations of their EMRs. This has allowed me a unique insight into “what doctor’s really want” as it pertains to the functions of their EMRs, and why they want it that way. It’s a good look inside the MD mind. I warn you, it can be a scary place.

Let me establish the setting. To understand the mentality of doctors, you have to understand their business model. That’s right, its business. I’m not even talking about health care anymore. When dealing with small practices, the doctors are at the very top of their business structure. They are the kings of the hill. They are at the apex of their pyramids, with each having as many as 10 or 15 staff members to support him/her. It’s a reciprocal relationship. The staff’s job is to supports the doctor and it is the doctor’s job to maximize revenues so that $$$ can trickle down to support the staff below and keep the business running. So what does this mean? This means that doctors are under tremendous pressure to generate revenue. In private practices, doctors are revenue generating machines. They have been doing this for a very long time and many are quite efficient at it. Likewise, so is the staff. The efficiency of the doctor determines how much $$$ he/she makes and also how much $$$ his staff and office get as a result.

Now, we tell them that they must buy and use an EMR to do what they’ve been doing for years. Remember, doctors are revenue generating machines. They don’t have time to waste. They can’t even afford to write properly. So what is their response? I’ll tell you, now… since you’ve been so very patiently.

Doctors don’t’ like EMRs. For the most part, EMRs introduce numerous impediments to doctor workflow. Many of the doctors I’ve worked with are only interested in the EMR because of the incentive plan. Others are doing it to avoid the 2015 penalty. Sadly, not one doctor I’ve worked with is implementing for the sake of improving patient care. But that’s not a surprise. Based upon the timing, this period would capture the demographic that is chasing government dollars or attempting to avoid the government stick.

One doctor I worked with sees about 60 patients a day, on a regular 8 hour day. That’s about 1 patient every 8 minutes. This is a highly established practice and generates very impressive numbers. The doctor expressed to me that he needs to see more patients each day. Cheers to that! Nothing wrong with increasing one’s availability. To do this, the doc wants the EMR to perform the clinical diagnosis. In other words, the EMR is to replace the doctor. If a patient comes in and complains of X, the system would automatically diagnose Y and prescribe treatment Z. This is completely possible by the way, at least programmatically (a highly detailed and comprehensive decision tree could actually be used, but that’s another story). What’s wrong with this? Well, a doctor’s medical function is to utilize the extensive clinical training to assess each patient’s physiology, medical history and unique circumstance and, based upon their based professional judgment, produce a personalized treatment plan. That’s why they get paid the big bucks. This particular doctor, who already makes big bucks, basically wanted to skip all the personal patient stuff just routinely diagnose and prescribe the same 5 treatments, automatically. He wishes for it to be so automatic that anyone could do it, that he need only sign off on the note. Perfect, so the doctor now functions only to provide his signature. I wouldn’t’ want to be his patient. But then again, he doesn’t need much more, he’s getting 60+ patients a day.

If you think from the perspective of the doctor, the EMR really gets in the way of “seeing more patients.” Many of the benefits of an EMR can be quickly realized by the administrative and clerical staff, but the doctor doesn’t care about that. And, when doctors have to deal with other doctors who use EMRs, they don’t like it much either. Whereas the typical patient file was perhaps a few pages long before, because it was hand written, now could be 15 pages long as much of it is automatically generated by the system. In the system we produce, one simple click on a “Routine Denies All” produces about a page worth of seemingly personal health information. A very click happy doctor could produce well over 20 pages with of clinical notes for a single patient encounter. Now… imagine the next doctor who has to read through that.

Don’t get me wrong. EMR technology is definitely the way to go. But with any new technology or now implementation, it takes time to evolve and become accepted. Software vendors will have to continue to develop improved interfaces, reduce clicks, and improve automation to compete with each other. In time, EMRs will be much more useful. It won’t be long I imagine. Just can’t wait to see a truly great EMR.

Patient’s Perspective.

It’s quite interesting to see how one’s opinions, biases and perspectives can alter one’s reality. In terms of patient perspective regarding the health care they receive, one’s level of satisfaction can have a real and profound effect on the treatment results. The phenomenon is similar to the placebo effect. When given the same treatments as control subjects, test subjects who believe they received the treatment express experiencing real effects. In many cases, real measureable physiological effects do in fact occur! It’s a type of mind over matter.

What this means is that when patients perceive that they received exceptional service and express great satisfaction, their physiology is altered to reflect this mental judgment, when in fact the care or treatment they received might not have been extraordinary at all. The same holds true for patients who feel deeply dissatisfied with their care. At this other end of the continuum, these patients may experience slower recovery, express greater degrees of pain and discomfort, overall condition is substandard compared to those on the opposite end of the spectrum.

Yes, I’m fully aware that each individual is unique, with unique physiology, needs, etc. But control experiments have documented that one’s perception of events have real impact on the consequences of those events.

In the unfortunate situation where adverse events occur, what is the most important determinant? Well, if you’re anything like me, you’d think that the ultimate determinant about anything personal regarding any particular person must be that individual’s opinion and perspective on their own situation. In other words, perhaps the individual does not perceive the event to be adverse, is completely satisfied with the treatment, makes no complaints or files any malpractice claims… did an adverse event really occur then?

Same holds true at the other spectrum. A committee of doctors attempts to convince a patient that the results of the procedure are within normal range, that recovery occurring normally, that the level of service and care were in fact exception. If the patient is not convinced, but is convinced of the opposite, that something tragically unfortunate has happened, one wouldn’t be wrong to expect this patient to express anger, frustration, file complaints… perhaps pursue a malpractice lawsuit. Well, did an adverse event occur? I’ve never filed a claim or spoken with a medical malpractice attorney, but I have a feeling his thoughts on this would be “as long as you believe it did” we have a case.

Government EMR Incentive / Penalty program.

Two methods of motivation that creates two types of customers.

So we’re nearing the middle of 2010. The ARRA incentive program states that a physician (which includes optometrists!) can begin receiving incentives as early as January 2011! That means there’s quite the urgency in getting a qualified EMR solution, utilizing it for 90 days prior to attestation and meeting those stringent meaningful use criteria. Yup, that’s all you gotta do to get Government $$$. Its so easy. Heck, its cake. But if you ask me, implementing an EMR for the sake of free Gov. dollars is like having kids for the tax write off. Yeah, from that perspective, its just not worth it.

Keeping in mind that there are two sides to this incentive / penalty program… namely, the incentive for early adopters and penalty for later adopters. Clearly, these distinct motivations create two types of clients for EMR vendors. From the EMR vendor perspective, the demographic that are presently interested in EMR (and EMR incentive dollars) are the ones who view the transition and subsequent headache of an EMR implementation as “worth their while.” Who are these people? Well, smaller practices that could significantly benefit from an 18k bonus the first year. For example, a family practice doctor who make 180k a year in qualified Medicare patients could receive 18k (a 10% increase) in revenue for their efforts in the 1st year. Not bad at all! But if you’re a specialist, say, an oncologist, your revenue increase might only be marginal and you might not feel the pressure... not yet.

But you will… by 2015 when the penalties kick in. By then, EMR vendors will experience a wave of the second kind… the late adopters rushing to avoid the penalties. In the second wave, highly specific EMRs will be in demand. These will be the providers who thought that the incentive provided to be the beta testers of new EMR technology wasn’t worth their time… that they can afford to sit by and wait while others scramble. And they are right too. By 2015, a lot of kinks will be worked out of existing systems. Processes, systems, infrastructures and politics would have evolved nearly 5 years. Smaller EMRs will go under, larger ones might just absorb them. Vendors will evolve, their products will become more secure, more efficient. Competition does wonders to reveal who is the fittest.

I’m personally seeing many smaller practices highly interested in transitioning. They are all in a rush. We’ll have to wait and see how things turn out in 2015…

What does Quality mean to you?

Quality... its that magic word the helps justify spending a little more money on product A when deciding against product B. Its that thing we try to figure out, try to measure based on where something is manufactured, something we compare and try to get the most of especially when we need to depend on that thing that we're trying to determine quality for. But what is quality? What does it mean to you? I'll tell you what it means to me.

Quality is the condition of being more fit or qualified for some purpose for some expected period of time. There are qualities of humanity, qualities of workmanship, qualities of friendship, qualities of service and of course, qualities of health care delivery. To me, saying that something is of good quality means that it is a better suited to perform some particular purpose for exactly the duration expected. In other words, when I bought that i7 laptop I expected it to out perform any other computer available AND do it for years to come. It has to meet these conditions to be considered good quality. Sure, its super fast, but if it crashes and breaks down in 2 weeks... it fails my second condition of performance duration, and thus, will not earn the distinction of "good" quality.

In terms of health care, quality really must address the entire health care delivery process, the results, long term benefits, patient satisfaction, competitiveness, sustainability... just to name a few. And since we have to pay for it, total cost is a major factor in considering quality. Cost containment continues to a driving force for health care reform. And it should be... we spend more GDP than most... yet constantly are rank inferior to some third world countries! In this regard, I can tell you... the quality of our health care system is "not good."

Which EMR / EHR?

EMR and EHR are the hot buzz words now a days. With all the talk of free money going around, who isn't excited? Essentially, the government has created an interest in an incentive program that has a clear cut implementation deadline and attractive pay schedules but lacks decisive standards, implementation criteria and software certification measures. We know we want it, we know how much we can potentially get, but no body really knows how exactly to get it! Come on Gov! "Show me the money!"

There have been announcements of specific criteria that the software solution (EHR) must meet in order to even be considered for the incentive program. Such solutions must either meet the ARRA specifications or, as it is speculated, meet the CCHIT certification. CCHIT is expected to be chosen certify body for EHRs. What this means is that non-certified solutions won't even be considered. Why should they? Physicians will see a plethora of fully certified solutions that all essentially do the same things. There will be a checklist of certified criteria and each vendor will deal with the devil to earn that stamp of approval. Its competition! This is free market at its best! The consumers will benefit as the vendors improve their products to meet standards and certification. So now its easy right? Just go out and buy the cheapest certified solution and you're set, because.. well, its certified and it will do everything the government wanted it to do for my practice, right? That's all there is to it. Well, not exactly.

First, if all you're interested in is getting some free money, then really that is all you need to worry about. Presently, Medicare and Medicaid have different qualifications on meeting certain performance metrics to qualify for the free $$$. The difference... quite simply, is that Medicare requires performance metrics during Stage 1 whereas Medicaid does not! So, if your practice sees about 24k in Medicaid patients... it appears that you're golden to receive the full blown $$$. All you have to do is utilize a certified product and you can get Stage 1 moola. If you're a physician who doesn't really care about revolutionizing your office, about making a transition to digital or about utilizing this technology for patient safety and improved patient outcomes... if this is only a strategy to get some government dollars, just buy the cheapest certified EHR and you'll be rolling in the free money!

to be continued...

Continued: The Best EMR Solution: In-house.

I left off describing some of the challenges of implementing an EMR for my optometry practice. I touched on issues relating to the conflicting perspectives of clinicians and managers, reasons and benefits for going electronic and the inherent problems associated with implementing such changes. I think I'll continue just where I left it... detailing some problems that arose during the transition.

I shamefully must admit that we still use paper. Our patients must provide us their information on carbon copy forms that will, at a later time, be interpreted and entered into the system (by me). This allows for problems related to illegible patient handwriting and unnecessary errors introduced in the data entry process. Furthermore, what I failed to mention previously yet has become a substantial problem is the wasted time lost during this redundant process. Although a good problem to have, when the office is busy, the weekends are spent 'catching up' on paper profiles. Its no fun at all!

Fortunately we are nearing the end of the "1st paper then computer" phase of our transition. I am nearly complete with the scripts that will allow patients to provide us with their profile, medical history and insurance information... all on the computer! An intelligent, adaptive script was created to ask only the pertinent questions. If you don't wear contacts, you won't have to answer any contact related questions. If you have diabetes, be prepared to provide a lengthy medical and treatment history. All of this will occur on a new workstation that is already up and running, currently used as a terminal for content lens training videos or for playing Disney movies to entertain the awaiting guests. The workstation is connected to our LAN wirelessly, which communicates to our server hosted remotely and all data is available in real time. Yes, I'm fairly proud. But its not done yet... but I just can't wait until it is. I'm so very tired of paper profiles.

Whats next? Plenty. I cannot express how vitally important it is to carefully plan and collaborate with the clinical staff every detail pertaining to workflow and interface for an EMR solution. The old adage that states, "measure twice cut once" comes to mind. In developing software, its better to know exactly what the end result should be and WHY, before you code. Coding is the VERY last step. You really just want to do it once. Imagine building a house and then find out you need to change the bricks in the foundation. If you're sensing a bit of regretfulness in my words, it is because I have learned this lesson the hard way. Now that we are nearly at our goal of a paperless office, I've just realized something profound. My software could be so much better.

Indeed, it can always be better. But a little more time spent investigating and planning can go a long way in producing solutions that have longer life spans, be more beneficial, and can save you lots of time and money. In my case... essentially everything has gone electronic. Our appointments are now fully web based. All invoicing and billing is electronic. My wife records anything via a computer with 22" LCD monitor... using mouse and keyboard, just as I had envisioned it. But therein lies the problem, the computer system in the exam room.

Prior to this transition, there was no patient-doctor-computer triangle. My wife seldomly had to turn away from her patient. There wasn't any real distraction or interruption in the work flow. But now, due to the improvements of technology, my optometrist must neglect her patient to interface with my computer system. I once heard that, "its not a problem until there is a solution." Well, its a problem now because there is a solution... has been for a while. They are called "Slates" and are revolutionizing how clinicians carry out their tasks. Slates are essentially super thin computers the size of a traditional laptop screens. There is no keyboard. Interface is via finger touch or digitizer pen, or both. To be effective however, slates must run special software that takes advantage of this unique interface. Ah... special software... there goes the weekends again.

If you've ever used an Apple iPhone or any touch screen device, you will immediately find the interface to be intuitive and refreshing. It just makes sense. My little 2 year old cousin plays a basketball game from my iPhone... he learned how to do it in all of 3 seconds. One major obstacle that EMR or any software tends to have are problems with the interface. When restricted to inputs such as mice and keyboards, inputting becomes unnatural. Its not the fault of the programmer, he's doing his best. Likewise, its not the fault of the computer either, it doesn't care how you interface with it, it just needs input to do its job. Slates, such as the newly introduced Apple iPad, can change all that. The computer gets its input without a keyboard or mouse, doesn't require the clinician to turn his/her back to the patient and may effectively eliminate that scandalous triangle that tried to wreck our happy home. Cool! Great! Lets go buy a slate and we're done... or are we?

Nope, not even close. As I said before, to be effective, slates have to have customized software to make them useful. Just as trading pen and paper for keyboard and screen in and of itself is a hollow achievement, further swapping the keyboard and mouse out for a touchscreen can realize only minor improvements. Yes, we can the triangle. And yes, we save space and the clinicians look real cool doing what they do. But are they faster? Will they be more efficient? Are they having fun? My tests on my Lenovo x60 Tablet with my existing EMR solution proved only slightly better. I am now challenged to create a new interface that can really take advantage of touch input. Here are some of the problems I can already foresee with slates.

1.) Big fingered people will experience difficulty with accuracy with touch interfaces.
2.) Fewer available options... (1 finger VS 101key keyboards and 3 button mice)
3.) How to type when you need to type. (Virtual onscreen keyboards provide no tactile feedback)
4.) Slates are lower powered and often limited. (iPad OS isn't multitasking, built in browser... Safari, does not render Flash)
5.) Battery power is limited
6.) Its really cool, so people will want to steal it.

As there are always challenges in any change, there are also benefits. I feel I have not done justice to the idea here. EMR solutions are good things! They are intended to improve the circumstances and I will tell you, I won't ever go back to paper. I'll close this entry with a positive note that addresses the title of this blog... "The Best EMR Solution: In-House" Why in house? One reason is this... turn around time on updates, large or small, is really limited to how fast your in-house IT department can produce them. In this case, I'll say about 15 weekends.

to be continued.

The Best EMR Solution: In-house.

A little over a year ago my wife and I started our first business together. For me, this would be somewhere along the lines of my 7th venture, but indeed my first in the arena of health care. Although the semantics of it all were a bit different... the general ideas are similar. Aspects of efficiency, work flow, data management, bookkeeping, customer satisfaction and of course the bottom line where all present. "Business is business," I always told my wife to give her peace of mind.

We were both excited. My wife was then a newly graduated Optometrist eager to provide her prospective patients with the best eye exams they'd ever had. I, an entrepreneur with a strong background in computer technology, was very eager to see how this business model and corresponding challenges would compare to my past technology related businesses.

Opposing Viewpoints:
In short, managing two optometry offices proves logistically different than running say... a pay-per-click search engine or a retail store selling computers. It is a completely different animal altogether. One could expect to see many challenges. The greatest challenge was that of the opposing viewpoints. My wife embraced the viewpoint of the clinician, whereas I took that of management and stakeholder. This was due to our backgrounds and specific roles in the operation. We both agreed that profitability was important, that achieving profitability directly affect us both. However our different positions produced different perspectives that lead to many clashing views. The remainder of this blog will outline the challenges specific to embracing and implementing electronic medical records. Of course, there were many other challenges but I won’t go into those.

Why go Electronic:
Simple… electronic technology is cool. It really is. But that isn’t enough to convince any provider to embrace it. Nor is it sufficient to convince any stakeholder or management to throw money at it. I’ll start with the bottom line… ultimately technology utilized by any business needs to assist in the sustainability and profitability of that business. In heath care, these factors are intertwined with patient safety and satisfaction. Failure to achieve either of the latter can result in expensive liabilities. The goal then was to utilize technology to the extent that it maximizes patient safety and satisfaction without compromising profitability.

We further agreed that implementing technology for technology’s sake would prove to be an empty achievement. Trading pen and paper for screen and keyboard does not automatically produce improvements of any kind. Real improvements are realized when something can be deemed quantifiably better, i.e. faster, easier, higher quality, lower cost, improved patient satisfaction. There are areas where electronic solutions are pointless. More often, there are areas that are beneficial at one level of the operation yet an impediment at another. Each organization must clearly define the circumstances and assess organizational needs to determine the appropriateness of transitioning to electronic systems. In our case, we operate an optometry practice with a single provider in partnership with a large retail chain. Therefore, our needs will vary from that of say, an independent practice with multiple providers.

1. Eliminate Paper:

We wished to eliminate our dependency on paper along with all associated wastes of time and supply costs. The idea of being able to immediately pull patient information without searching an alphabetized filing cabinet seemed very attractive. In practice, it saves us only a few seconds at best. Keep in mind that we are a new practice with ~ 1600 patients thus far. An established practice with 10,000+ patients should realize tremendous time savings in this area.

Having this data in electronic format allows for a plethora of additional functions. If it’s quantifiable, a few lines of code can produce valuable information that can help guide the practice’s operations and decisions. Although pulling one patient’s file has been improved by a few seconds, processes which involve all patient files that might otherwise take days occur in milliseconds. That is but one substantial benefit to utilizing electronic systems.

But it’s not without its burdens. Keep in mind that data must first be entered into the system. Presently, we do not allow patients to access our office computers (I’m working on that.) Therefore, all initial patient paperwork is still… well, captured on paper and later entered into the system. This creates two main problems. The first has to do with legibility. Whereas patients have been complaining about doctor’s handwriting for years, now we are experiencing the reverse when attempting to read patient profiles. It is often difficult to make out the various handwritings and short-hand used by patients. The second is an indirect result of the first. This added step of data entry introduces another opportunity for user error. Data entry requires and interpretation of the patient’s handwriting and thus, can be affect by numerous factors. To alleviate this problem, we plan on having the patients fill out their information on a workstation connected to our system via a secure website. The workstation will be positioned to allow for patient privacy. We shall continue to offer paper forms for patients who prefer this method.

To be continued...

EMR Vs EHR: Whats the Difference?

What is the difference between EMR and EHR? Certainly, most know they are acronyms representing Electronic Medical Records and Electronic Health Records, respectively, but what really is the difference?

EMR is at present (1.24.10) the more prevalent term and hot topic, according to present Google search trends. However, careful distinction and differentiation between EMR and EHR will soon lead to the switching of market prevalence of the two terms. Vendors will cease to use these terms interchangeably as the market becomes more aware of their differences. One important point: US health care reform is about EHR adoption and implementation, the term appears countless times in recent legislation whereas EMR not so much.

Okay... what is the actual difference... well again quite literally, EMR and EHR differ in their central term, Medical verses Health. Specifically, the "medical" in EMR implies a practice or physician centered approach to health care. The benefits of EMR solutions originates from improvements in how the physician or practice can use technology to acquire, store and utilize patient information to produce better, safer patient outcomes at reduced costs. EMR systems are specific, often propriety and typically owned by the physician or practice. Although EMR systems may facilitate ease of electronic exchange, interoperability with other systems it is not a central goal of EMR systems.

On that note... EHR is EMR with interoperability built in. The context of EHR is therefore much broader than EMR. The "health" in EHR represents the focus on the patient. EHR is patient centered and thus not specific to achieving goals of any particular physician or practice, nor is it wholly owned by any contributing physician or practice. EHRs are achieved through a collective effort by all participants. It is an aggregate health record for an individual made possible by the joint efforts of all the doctors and staff involved in the individual's health care.

Why is this important? EHR technologies form medical communities. You can think of it as a collection of EMRs that work together to produce one complete and continual health record. Perhaps one very large and comprehensive system might someday be used by all providers. For now, technologies are under way to interconnect existing systems and create the interoperability necessary to achieve the goals of EHR.