EMR – What’s the race all about?

One of the most interesting things about health IT applications, especially Electronic Medical Records (EMR) is that ever since its inception there seems to be an upward trend in the product demand. Overtime healthcare providers have realized the potential advantages that EMR technology has provided and are likely to provide to the healthcare industry. Every now and then you would come across physicians discussing specialty focused EMRs, free EMR, and especially certified EMR.

More interestingly, given this increasing popularity of the certified EMRs, the product vendors have started experiencing cut throat competition. No wonder why over the past few years, health IT has been considered to be one of the most rapidly growing industry across the US. The availability of more than 700 vendors, intensively trying to capture the market share, is clear support for the aforementioned statement. While there are thousands of reasons behind the increasing competition, the government’s financial incentive program could be attributed as one of the vital ones.

Being part of the health IT industry, we are all aware that the government requires meaningful use of certified EMR on part of physicians to consider them eligible for the program. No doubt, this is one of the essential criteria to qualify for the incentive funds. Realizing that certification was becoming a crucial requirement for physicians, be it the one who charged a monthly subscription fee for its EMR or provided free EMR, the vendors made sure that their software fulfilled the certification criterion. The logic was simple; keeping pace with the industry requirements would help them influence the client’s choice.

“Be it any industry, competition amongst the vendors can never end. In fact, new regulations and opportunities are likely to increase the existing competition. This is what is happening in the EMR industry. While the existing renowned vendors are trying their best to retain their clientele and attract more potential clients, novice vendors are enthusiastically trying to keep up with the pace”, says a San Francisco based health IT consultant.

It would not be absurd to say that besides helping physicians with clinical procedures, EMRs are also becoming a marketing tool for the vendors. The reason is, if the EMR conforms to a physician’s requirements, even if it’s not a free EMR, the physician is likely to refer it to another colleague – eventually creating a chain of references. Of course, at the end of the day, it is the vendors whose product is being promoted. However, such a situation increases the burden on the vendor to maintain the reputation in the market.



EMR – The word on the Street – Part 2

Continuing from where I left off 3 weeks ago, EMR – The Word on Street – Part 1, most patients tend to have very unique perspectives about the EMR technology. Still not accustomed to the change like most physicians, patients are more intrigued and fascinated by the drift towards automated healthcare. While I have not had the chance to reconnect with the group, I had not quite finished the account of our detailed discussion on health IT and the wondrous world of electronic medical records.

I was able to establish that the patients in the group did not have any inhibitions towards the electronic medical records technology. Even when invoking the subject of privacy and health information exchange, most of the group members felt secure, citing that they ‘trusted their doctors’. Despite being an ‘awww’ moment, I was surprised at this response. One member quoted, “If my doctor is using an EMR, I expect he has gone through all the hurdles to make sure that my information is safe and secure. They are professionals and they know how to do their job.” That statement summaries what most patient feel about health IT adoption, instead of being personally concerned about the security of their health data, patients expect physicians to play that role for them, as professionals.

While providers plan for such risks and unauthorized disclosures, electronic medical records change the job description significantly. Digitized data is more susceptible to theft. Not only is data exposed in its physical environment but also vulnerable to cyber theft. However, the problem is that most providers tend to rely on basic firewalls and commercial encryption software available at economical rates, while others simply leave the security up to their hosting parties and EMR vendor. Given the amount of recent breaches, such methods are no longer acceptable. Ensuring patient safety and maintaining confidentiality should be one of the top priorities for physicians. With health information exchange (HIE) in sight, physicians should look to train their staff to work within such an environment whilst planning for contingencies.

However, despite their trust in provider professionalism, the group did not take lightly to the possibility of physicians selling their patient’s personal health information to disease control bodies, etc. even when de-identified. I had to assure one of the group members that it would be a HIPAA violation and against the ‘rules’ to sell patient information without prior consent. One patient joked about reading the fine print of every medical document from  henceforth.


Costs to consider for EMR implementation

Despite what most EMR vendors may want you to believe, there is more to budget for than monthly costs along with the initial training and implementation fees. While costs have decreased significantly over the last few years, most EMRs still require a small fortune. Many providers still rank cost as the highest in hurdles to adoption and while the government may incentivize EMR adoption through meaningful use, the initial investment is still to be paid by the provider alone.

Research and Analysis (Sunk Cost)

What most providers do not account for is the opportunity cost of researching and analyzing the EMR product. While for some it may just translate into free time and hectic schedules, for others it may require sacrificing available time slots for patients, resulting in business loss. One should also include the cost for visiting onsite references, hiring staff overtime for analysis or consultation fees.

Hardware Costs

Most EMR vendors are able to provide hardware specifications for optimum results. While Software as a Service (SaaS) model for EMRs may reduce the upfront spending, those shifting from paper will still need to set up exam rooms and nurse stations. Recognized EMR vendors often work with hardware vendors to provide their clients with discounted deals and bulk buys.

Software Costs

EMR users are required to pay licensing cost, either upfront for a client server model or on a monthly basis for SaaS based product. Physician’s assistant and Nurses may also require separate user licenses apart from the provider’s own. The upfront licensing cost for a client based server can range between $5000-25000 depending on the solution and user base while some hospital based vendors may even charge in excess. SaaS based EMR vendors usually charge around an average of $500 per license.

Training and Implementation Costs

The training and implementation costs can vary significantly from vendor to vendor.  Most EMR vendors prefer to train providers through remote desktop access, because not only is it more cost effective but flexible too. Sessions can be configured to suit the user requirements, while personal sessions can be set up at the discretion of the user, independent of location. However, most practices still prefer onsite training which may cost more but help smoothen the implementation process itself. Training hours can be billed somewhere from $100-300 dependent on the method and vendor.

Support and Maintenance 

Hospitals and large care corporations are able to hire dedicated staff to provide ongoing assistance when and wherever required. However, EMR vendors especially for SaaS based products are able to provide offsite support through telecommunication and online portals. This method is more cost effective in most cases and one of the major reasons driving the adoption of SaaS based EMRs. These costs however do not include hardware maintenance in most cases which then would have to be arranged independently by the provider if required.

Other ongoing costs

It is important for the provider to consider other miscellaneous expenditure that may or may not be required during or after the EMR implementation. These can include hardware and software upgrades, new employee training, additional feature requests and customizations.


EMR Workflows – How Essential are They?

Long gone are the days when an EMR was recognized as a mere documentation system. Electronic medical records over a period of time have evolved into EMR workflow systems. The workflows allow for EMR customization which reflects on practice clinical needs, personal preferences and business requirements.

Workflow Management with an EMRAll electronic medical records have workflows but the more effective EMR is the one which defines its workflow for optimum output. These definitions reduce manual navigation for the user and increases productivity. Ultimately, the effect of workflow management technology on productivity is pragmatic. A recent survey was conducted on the impact of an EMR workflow management system on usability and productivity in numerous practices. The results were based on (revenue, billing, charges, visit, quality review, staff/provider ratio, charting time and refill turnaround time). The results show Increase in revenue, billing, visits and visit charges, and quality review scores while equally there was a decrease in staff/provider ratio, charting time, and phone message and refill request turnaround times. The survey suggests that the combination of workflow management and patient charting can greatly increase user satisfaction, return on investment, and practice productivity.

EMR SurveyAnother survey conducted by AMIA describes how improving EMR usability can help prioritize improvements in EMR workflow based on human factors engineering. Assessing the usability along with proposing required amendments in EMR systems was one of the fundamental objectives of this approach, which would eventually improve operations and streamline practice workflows. There were various ways of approaching this development, such as conducting studies that would involve physicians to quantify time spent on EMR based clinical documentation. Another way was to ascertain the amount of change in existing workflows when utilizing electronic medical records, by carrying out a research study of physicians migrating to EMRs from paper records. Similarly, a number of physicians were selected to identify and evaluate the factors influencing human behavior and reaction to improve the usability of EMRs. Lastly, another method incorporated a task analysis to replicate alternative approaches, along with establishing opportunities to improve functionality.

Studies were implemented in series fashion in order that insights from one study would serve as inputs to the next. For example, the first method illustrated that majority of the physicians were trying to document clinical findings and other documentation during the patient encounter. However, it was determined that regardless of the approach used for clinical documentation; physicians would be unable to document tasks performed during the actual encounter. Therefore, the groups began to focus on the development of systems which allowed clinical assessment and tasks performed to be recorded during the patient encounter.  In the end, the aforementioned methods proposed several different types of projects that would enhance the usability of EHR systems.

There are very few EMR’s in the industry that produce such productive workflows. EMR workflows are all about the user, creating the right workflows, which are well defined and effective at the point of care.


The Meaningful Use Surprises

The final rule for meaningful use stage 2 should be out any day now and while most of care community anxiously awaits the announcement, the industry experts are expecting little to no changes from the proposed rule, released earlier this year. The stage two of meaningful is to build on the stage one objectives ensuring that providers are able to utilize EMR technology in a constructive manner and add value to the care process. The focus of the second stage will be on ‘advanced clinical processes’. Keeping in line with this theme, stage 2 is expected to feature clinical decision support, electronic data sharing and patient engagement as its main components.

Farzad Mostashari, the National Coordinator for Health Information Technology admitted that there could be some surprises in store for providers looking to attest for the meaningful use stage 2 saying, “I think that it would probably come as a little surprise we will pushing on standards based exchange and on patient engagement aspects in addition to continuing really what was in stage 1.”

Health information Exchange seems to be the most significant concern at this point in time. Providers were aghast with the proposed rule and its interoperability requirements, with most admitting that there electronic medical records simply did not possess the capability to comply with stage 2. There was a definite gap between the technology available to providers and what CMS was anticipating. Dr. Mostashari in response to the concerns raised by the medical community expressed that the ONC does listen to the concerns carefully. He explained, “We have been at this for a while now and we have to really balance the needs of the situation against how fast the industry and providers can adapt to change.”

The ONC has also outlined a plan for standardizing health information exchange and will seek to accomplish three major aspects within this year, which includes a common set of rules for governance of HIEs. This also reflects the CMS stance on health information security with the meaningful use stage 2 proposed requirements.

Patient engagement is an important aspect of the healthcare reform. With the government set on introducing a preventive care culture across the nation, health system interoperability will undoubtedly benefit patients by making care more accessible and affordable. The proposed stage 2 rule adds follow-up reminders, patient education and patient access to electronic medical records as core measures. The public response has been positive with patients being allowed to access their own information for downloading and personal use.

While there has been no indication as to whether CMS has relaxed the attestation period from one calendar year to 90 days as suggested by AHA, most providers are hoping for some sort of relief from the authorities. For now it seems that the best bet is to make sure that you retain what you have learned during the first attestation period and go from there.


EMR – The Word on Street – Part 1

I have always enjoyed discussing state of healthcare and its affairs with physicians, EMR consultants, health IT gurus and basically anyone with professional knowledge that cares to throw a bone. However, recently I got engaged in a friendly debate with a group of friends, unrelated to the world of healthcare. It was fascinating to learn their views on the healthcare reform along with the turn towards EMRs and electronic information exchange. There is much to share, hence I have decided to write a series of blogs regarding just this. In this post I will be covering exam room encounters and the general perspective of non-medical professionals about the world of health IT and Electronic Medical Records.

As a patient, your view about the healthcare reform is simple, ‘computers are better at storing information, less prone to human errors and help save time, which is why electronic medical records are important’. I had to educate some members of the group to extract their opinions about the subject matter, but nonetheless it was a unique experience and I thoroughly enjoyed the feedback from people outside the care structure.

Most of the participants had not yet encountered a physician using an EMR within the exam room, while the few who had done so found the interaction quite satisfactory. I understand that my sample data is limited, but it was enlightening nonetheless to understand some of the concerns a patient might have. This is how one participant described his encounter, “It was fine. I could see the screen so I knew what the doctor was doing. It did take him a few seconds to type, but the encounter seemed really structured as if he had prepared a set of questions beforehand.”

Physicians are quickly improving exam room technique and ethics while documenting on the EMR. I myself have experienced that change. Sharing the screen with the patient and educating them simultaneously can add to the patient’s experience. While I may not have enough information to determine whether or not electronic medical records are making patient encounters more structured, the group of patients that I met, seemed to think that they have. It is also true that most physicians like to maintain an air of professionalism in the exam room, which sometimes results in robotic encounters. Although, with that said, structure and standard of procedure is not a bad thing in medicine.

After explaining the basics of the clinical decision support (CDC) system in an EMR, I invited some questions from the group. Most of the participants seemed content with the structure, admitting that the EMR system (read more) will enable physicians to make more informed decisions. One group member expressed his relief, confessing that he would still prefer physicians to have the ultimate control over clinical decisions as he was not ready to leave his health to computers. There is a good feel about the healthcare reform and although most individuals are unaware of how it affects them, the government’s backing of health IT adoption has provided reassurance to the general populous.


EMR – Bespoke Vs Off The Shelf

The recent surge in health IT has helped several innovative companies proliferate the healthcare market. Healthcare in the US has traditionally lagged behind other industries in terms information digitization, but the government’s backing has lead to the rapid growth of health IT with CDC reporting an overall EMR adoption of 55% with the country.

While electronic medical records have existed for a long time, it was not until late 1990s that vendors began to produce commercialized solutions. Some hospitals at that time had already been using bespoke EMRs, that were specifically designed for their requirements. With limited information exchange at the time, these bespoke systems worked through intra office networks utilizing standard security protocols. Health Insurance Portability and Accountability Act (HIPPA) was introduced in 1996 anticipating growth of health information exchange.

Today providers have a choice between 800 EMR vendors providing a range of specialist products. EMRs have come a long way. Working closing with the early adopters, EMR vendors were able to focus on usability leading to the development of interactive solutions. However, with bespoke EMRs there was no standardization and interoperability was always an issue. The government attempted to sort this out through the meaningful use (MU) campaign, highlighting effective methods of EMR utilization.

While Health IT had already started to gain momentum by that time, the government’s support under the American Re-investment and Recovery Act brought a host of IT vendors to the healthcare industry. With the basic functionality outlined in the MU program, vendors had a base to build upon. More license based applications started making their way into the market. This trend also instigated a change in deployment models, as cloud and web-based models quickly began capturing significant market shares.

The license based products were more cost effective than their predecessors. Deployment time was quicker and there was a marked improvement in functionality while they lacked the extensive flexibility of bespoke systems. Bespoke design is in accordance with the organizational model, hence increases its competitive advantage.

However, since the application is uniquely configured, the organization’s reliance on the vendor increases significantly as well. Bugs and errors are a common place for bespoke software as testing is limited. Modifications and upgrades are expensive while development takes time and requires significant resources. Lastly, bespoke vendors usually don’t provide support services and practices have to employ technicians privately in most cases.

These hassles are greatly reduced by purchasing licensed software. Training manuals and support is readily available while extensive testing, modification and live runs reduce the chances of unexpected errors. In the world of health IT, established EHR vendors were quick to gauge the discrepancies in workflows. Application rigidity was a discouraging aspect for most providers, hence established EHR vendors allowed basic customization to increase flexibility.

“Off the shelf electronic medical records are less of a hassle. Most physicians today are more tech savvy. I myself use a tablet for most tasks. I think it’s more about getting a good vendor with reliable support and decent functionality. Everyone would like a custom-made EMR but simply cannot afford it. More importantly, we just don’t have the time.”, says one physician.

While there are advantages and disadvantages of both types of EMR systems, the size of the enterprise is the key factor in determining product selection. However, there are plenty of good off the shelf EMRs to choose from today. All you need is to find the right fit for your practice.