EMR/EHR Blazing A Path For BI

For most of last year I did Business Intelligence (BI) consulting in the consumer goods industry, hence the long time between my last post and now. So for my first post of the new year, and probably many more posts throughout the year, I will highlight EMR/EHR implementation and BI.

As some of the EMR implementation goals are now beginning to be realized and providers becoming more prepared to handle electronic records, BI possibilities are emerging. Healthcare providers can utilize BI strategies to not only improve business practices, but also improve patient care.

KLAS released an in-depth report, “Business Intelligence: Making Cents of Performance,” including research on market trends, BI needs, and vendor performance. Healthcare IT News summarized the key findings as follows:

• The ‘pay for performance’ model and other reforms will force hospitals to more carefully analyze performance measures to identify inefficiencies, quality gaps, supply chain inadequacies and overall performance metrics.
• Although enterprise BI solutions are growing in acceptance, industry-agnostic solution vendors are still making a good showing in healthcare.
• Using BI to make key decisions is just the beginning; providers need their analytics solutions to help them perform predictive analysis with a reasonable level of confidence.

I’ll explore the current state of BI and EMR/EHR based on the key findings by KLAS in upcoming posts.

EHR software market to exceed $6 billion

Markets and Markets reported the electronic health record (EHR) software market is poised to exceed $6 billion by 2015. In addition to government initiatives toward development of EHR, they also attribute the rising demand for healthcare cost containment and the need to improve the quality of healthcare services are driving the growth rate in this market. This is a huge jump as the EHR market was only about a $2 billion industry in 2009.

Not so surprising, they also noted that web-based EMR solutions or ASP models are gaining popularity with small-sized healthcare practices and physician offices. The popularity of web-based and ASP EHR solutions for smaller providers will force many smaller providers to upgrade their IT infrastructure, i.e. broadband access, hardware, LAN/WAN, software platform, etc. Therefore, IT opportunities should trickle down to smaller IT integrators and consultants.

EMR Implementation Training

One of the things that always surprised me was the level, or lack thereof, of basic computer skills that existed within most providers’ offices. This low level of computer skills existed not only with office personnel, but also with doctors and nurses. Therefore, when implementing new computer software a lot of time was spent providing basic computer training in addition to software specific training.

With EMR implementation it’s highly critical that both medical and office personnel are trained on EMR systems. If they are not properly trained they will become frustrated, and possibly, unproductive. An unproductive doctor and/or nurse in a clinical setting is not a good thing. If that happens it could sabotaged the best of EMR implementation projects.

Keep in mind that no two providers are alike and work flow processes differ from one provider to another, here are a couple of training recommendations when providing EMR training that are applicable across the board. First, access the computer skills of everyone that will be using the new system. If basic computer training is needed, include it in your training curriculum. When providing basic computer training take nothing for granted, heck, you may have to teach keyboarding, how to operate a mouse, etc., just be prepared to get the users up to speed on the most basic of computer skills. Secondly, provide one-on-one training when feasibly possible. I found one-on-one training works best for this set of users, especially for smaller to medium sized providers. If this is not possible, try to have at least one experienced (or a well-trained user) to support every two doctors during the initial days of “go live.” And thirdly, require ALL medical personnel to attend training, even if it means night and/or weekend training sessions. This may require flexibility on your part to accommodate everyone’s schedule, but it will be time well spent to have trained doctors/nurses using the system on day one of “go live” versus doctors/nurses doing OJT on the day of “go live”...

Remember the best way to eat an elephant is one bite at a time, so save yourself a headache by implementing EMR in phases. Implement only one process at a time before turning up the next process. Because if glitches are caused by implementing an EMR system, i.e. billing, clinical, prescriptions, etc., the emergency system just may get activated (see cartoon)...

EMR Costs, Just Like Hens in a Hen House

On the heels of my last post, EMR APP for iPhone, I mentioned the cost of the EMR iPhone app was less than $200. Keep in mind EMR deployments can cost millions. In a report by the Free Library, “EMR: one hospital that got it right,” Dr. James Leo, associate chief medical officer for Long Beach (Calif.) Memorial, stated "EMR [systems] can cost hospitals $20 million to $200 million due to implementation, vendor and hardware costs, staff training, and upkeep." Smaller providers’ can expect to spend from $25,000 to $60,000 per physician to deploy an EMR system. For smaller providers this projected cost doesn't cover consulting, training, add-on-software, and upkeep.

Despite the availability of EMR iPhone apps, EMR deployment is still a costly project. For this reason, a good case can be made for EMR implementations to hire an external EMR consultant, which is not employed by the vendor, is money well spent. Go ahead, laugh. Coming from an IT professional, this is like the rooster telling the farmer he needs more chickens in the hen house, right? But for a project of this magnitude, whether it’s for a small provider’s practice or a large hospital institution, having someone on board that’s not affiliated with the vendor but has rolled out one of these systems is money well spent.

Just like the farmer will be ecstatic with the additional hens in the hen house once all of his hens are producing more eggs, providers will be happy that a set of non-partisan eyes are part of the project team when implementation challenges are encountered. As IT professionals, we know that implementation challenges will be ecountered.

Click here to read the entire article from Free Library.

For Everything Else, VistA

I haven’t hid my affinity for open source code, especially as it relates to HITECH’s requirement for providers to implement EMRs. I’ve come across an interesting article from Washington Monthly, "Code Red," that does a nice job articulating my viewpoint. This article contrasts two EMR implementations, one institution uses the much touted open source system initially written for the Veterans Administration hospitals called VistA and the other institution implemented a proprietary solution developed by Cerner Corporation.

In a nutshell, the institution that used the open source system achieved dramatic positive results, i.e. the number of medical errors and deaths decreased drastically. Whereas the institution that installed the proprietary system, experienced disastrous results, i.e. in some cases two doctors were required to attend to a patient whereas previously only one was needed and the mortality rate for certain patient populations more than doubled. Although I’m sure a similar contrast could be made extolling the virtues of using a proprietary system, however, I think this article does a good job of articulating my position overall for open source code EHR.

In addition, this article also shed light on other possible unintended outcomes resulting from HITECH requiring providers to implement EHR a such a fast pace.

Read the complete Washington Monthly article here.

EMR Usability, Leapfrog or IBM OS/2

I stumbled across an interesting article this afternoon on FierceHealthIT by Anne Zieger, “HIMSS says poor usability cuts EMR adoption.” In her article she basically reports that HIMSS published a paper outlining usability as one of the key reasons that will prevent EMR adoption. In their paper, HIMSS proposed that usability should become a part of the EMR certification process. HIMSS EHR Usability Task Force chair Jeffery Belden, MD stated that if certified EMRs were guaranteed to be user-friendly, decision-makers would feel more confident in selecting such systems.

What concern me are the diverse computer skills among the provider community. Some providers take to technology like a fish to water, and there are others where it’s more like forcing a kid to eat spinach. Usability testing in its purest form is generally done using black-box testing techniques, whereas the aim is to observe a random set of people using the product to discover errors and areas of improvement. If the usability test group is skewed towards the technology adverse providers, the resulting interface could end up resembling a Leapfrog educational gadget. Or if it’s skewed towards the technology favorable providers the interface could end up resembling IBM’s ill-fated OS/2 operating system, a PC operating system that was only appreciated by the most technical savvy of technologists.

Yes, I have over simplified the issue of usability certification. Surely the random collection of usability testers (providers) would be a fair representation of the skill set in the provider community. However, the criticality of assembling a “fair representation” of the provider community does give me reason to pause on the idea of usability certification for EMR applications to "guarantee" user-friendliness.

Read the complete HIMSS paper here.


Read FierceHealth IT article here.

IT, it rolls Downhill

I was having lunch with one of my more technical savvy, or so she thinks, doctor friends the other day. Just like most physicians, she’s contemplating implementing an EMR application for her family practice. After visiting with several EMR vendors, she decided that she was going to implement an open source EMR solution because of its cost effectiveness, plus she has a longstanding relationship with her current system integrator.

Since our last discussion, someone, another vendor, had convinced her that a software as a service (SaaS) solution was the way to go. It's quite possible that a good financial case can be made for an EMR SaaS solution as opposed to other EMR solutions. But what surprised me was that she was not aware of the inherent risks of implementing this type of solution. I reminded her of when her web site hosting company closed. The frustration it caused and length of time it took to get her site back online. Actually, the bulk of the frustration came from her trying to get the source code for her site (she never had a copy). I warned her that experience would be very similar if her SaaS provider tanked, only it would be MUCH worst. After our discussion, she realized she had more work to do before coming to decision.

I begin to wonder who responsibility is it to outline the risk of the various EMR solutions to a potential customer? Should each vendor outline the inherent risk associated with their solution? Or should a physician research and understand the inherent risk involved for each possible solution? For large clinical practices and hospitals, this is not an issue because this falls squarely on the CIO, IT Director, or to the most senior ranking IT executive. However, an IT executive would be aware of the inherent risk in each solution platform and would carefully and thoroughly explained the risk to all stakeholders ;)

As the healthcare IT reforms begin to be implemented, vendors, software developers, and system integrators will merge, disappear and possibly default. "Things" will begin to roll downhill and IT will be sitting at the bottom of the hill. If the magnitude of this problem is great, that hill will be Capitol Hill. We all saw what happened to the last industry execs that visited there.

CPT Code for Computer Support

The Los Angeles Times ran a story Sunday, “Electronic Medical records have people abuzz. What’s the reality?”

“Primary care physician Matt Handley believes that information technology enables him to provide better patient care. So much so that he recently spent an afternoon hooking up a computer and DSL line at the home of a patient so he can contact him more frequently.” Click here for the complete article.

I found this to be a very good unbiased article because here lately there has been some negative chatter in the press for electronic medical record applications by a few in the medical profession. So it’s refreshing to see a “real-world” physician publicly profess their support for healthcare IT in a major news publication.

BTW, what’s the CPT code for in home visit for computer support? Dr. Handley may need it..

Opportunity Awaits, Open Source EMR

Linux, MySQL, PHP, Joomla, Audacity, the list goes on. I love open source technologies and applications. The lure of an open source medical practice software package is its price, FREE and there are several packages to choose from:

OpenEMR - a free medical practice management, electronic medical records, prescription writing, and medical billing application.
MirrorMed - a web-based application that is capable of running a healthcare practice. MirrorMed shares code with FreeMED, and OpenEMR.
FreeMED - GPL-licensed Electronic Medical Record and Practice Management system for medical providers that runs in any web browser in multiple languages. It provides an XML-RPC backend and multiple import and export formats, as well as reporting and other features.

The concern, or opportunity, with open source EMR applications for small physician practices is ongoing support. During the early 90s in my professional career as a regional IT Integrator we installed Linux running SAMBA fileserver in small offices. At that time, if a small business wanted to install Windows NT server along with the appropriate license fees cost an “arm and leg”, so to say the least we did VERY well. What I learned during this time was most small businesses had a brother, brother in-law, a kid in high school, nephew, or some other family member that provided basic computer support, i.e. adding users, shares, etc. However, Linux wasn’t a OS that was being discussed in A+ training classes, nor discussed in basic networking classes and only the most geeky of brother in-laws even knew how to pronounce Lin-us, oops, I meant Linux. So after implementation, these small offices had to contact us, or should I say contract with us, for ongoing support. In most cases, even with the ongoing support fees, the Total Cost of Ownership (TCO) was still much less than the TCO of Windows NT Server and the appropriate license fees over a 3 year lifespan. This was a WIN/WIN scenario for both the supplier and client.

But we did have a subset of clients that were upset their TCO were more than the intial cost of implementing the solution because of ongoing support costs. Although the ongoing support fees were explained upfront prior to implementation, this subset of clients believed their “family hackers” would be able to give them free support as they have always done. When their displeasure with our support fees drove them to seek another vendor there was none in the area that was familiar enough with Linux to support it, and there was no manufacturer to call because it was an open source product, so in a way we were the only ones that could assist them.

In any case, as the face of Healthcare IT radically changes, and with the federal government stimulus package earmarking loans and grants for providers to deploy e-health records, now is the time for savy IT Integrators to develop a niche market using open source EMR applications.

It's EHR, not EMR, To The Rescue

While sitting in the dentist office the other day, I perused an April 6, 2009 issue of Time magazine. The article that got my attention was “Wrong Prescription” by Scott Haig, M.D. He made a couple of points, if not totally inaccurate, they were a far stretch from practicality. So much so, that I finally decided it was time for me to start my Healthcare IT blog, an idea that I've been tossing around for about a year.

In his viewpoint article, he ascertains “that the Obama administration thinks it has discovered a magic bullet in the drive to lower health-care costs: electronic medical records (EMR).” Firstly, the current administration plan calls for the implementation of Electronic Healthcare Records (EHR) not EMRs. The media toss these two terms around interchangeably however there is a difference. Electronic Medical Records vs. Electronic Health Records: Yes, There Is a Difference, a HIMSS Analytics white paper by Garets and Davis described it best, “the EMR is the legal record created in hospitals and ambulatory environments [or any provider's environment] that is the source of data for the EHR. The EHR represents the ability to easily share medical information among stakeholders and to have a patient’s information follow him or her through the various modalities of care engaged by that individual. Stakeholders are composed of patients/consumers, healthcare providers, employers, and/or payers/insurers, including the government.” The EMR is for a specific provider's entity and EHR is to be shared. This ability to share a patient’s EHR among the various stakeholders is where efficiencies are gained, hence lower health-care costs.

Secondly, Dr. Haig suggested that an EMR will make it easy for a physician to create hyped-up diagnoses and inflated bills. An EMR will not make it any easier for a physician to create a hyped-up diagnosis than a blank prescription pad does. For providers that want to partake in fraudulent activities, an EMR application will not stop it, just like a copy machine doesn’t stop a person from producing fraudulent documents. So should progress in this area be stopped just because of what a small minority of sinister providers may do? I think not.

Basically, the majority of research does suggest implementation of EHR will lower health-care costs. In 2005, Health Affairs published a study, “The Value of Health Care Information Exchange and Interoperability” by Walker, Pan, Johnston, Adler-Milstein, Bates and Middleton which summarized net savings from national implementation of a fully standardized interoperability between providers and five other types of organizations [EHR] could yield $77.8 billion annually.


The bottom line is this, if we are to deliver higher quality, safer, health care at reduced costs, digital records are needed to help both providers and suppliers achieve this lofty goal.