Free EMR by Medicare?

I’ve been working with John Deutsch of EMR Experts, Inc. and I invited him to be a guest blogger on my blog. Here’s an article John sent me about the Free Vista EMR offered by the government. While I think the news about Vista being free came out about 2.5 years ago, the information about adopting it is still VERY relevant. Probably because the EMR adoption level is so low.

Enjoy John’s take on the government’s “Free EMR.”

Is anything ever free these days? Maybe so.

Instigated by the incredibly slow adoption of Electronic Medical Records (EMR) by doctors across the nation, Medicare is announcing it will begin offering doctors free electronic medical record software solutions.

Both upfront and ongoing costs have been critical factors in the lagging EMR adoption rate. Medicare hopes that by providing doctors with a free or very low-cost system, doctors will readily adopt EMR putting healthcare providers in America on a common system, thereby, providing Medicare and the general public with obvious, health, reporting and billing benefits.

The proposed system is VistA, (Veterans Health Information Systems and Technology Architecture) the widely popular system built by the Veterans Administration.

The adoption of VistA has resulted in the VA achieving a pharmacy prescription accuracy rate of 99.997%. Due to the implementation of VistA, the VA also outperforms most public sector hospitals on a variety of criteria.
The VistA system is public domain software, available through the Freedom of Information Act directly from the VA website or through a network of distributors.

Installed in over 1300 inpatient and outpatient facilities, the system is well-established and quite successful by EMR standards.

But can a system designed for a large organization like the VA also work for a solo practitioner family practice office?

A doctor in a New York Time article writes:

“It is one thing to use a system that someone else installed and someone else maintains. It is another to get a set of disks in the mail and do it yourself.”

Those who have tried to install VistA on their own would agree.

“Giving out a version of VistA is a great idea,” said Dr. David Kibbe, director of the Center for Health Information Technology at the American Academy of Family Physicians, a group that has been working on the project. “But at the beginning, there was a lot of wishful thinking. They said, ‘We’ll just release it.’ I said, ‘Where’s the fairy dust?’ ”

The problems with the healthcare sector and its slow adoption of electronic medical records are much deeper than some would like to admit, and viable solutions have been hard to come by.

The healthcare system is extremely fragmented, with thousands upon thousands of practices all practicing differently, using different billing systems, with different levels of computer proficiency, and different workflows.

Building a one-size-fits-all system has failed in the past and will likely continue to fail. The fact that over 300 different vendors currently develop and market EMR software attests to the need for customization.

The need for pre- and post-sale customization is a reality in every practice since every practice operates differently. Even practicing physicians within the exact same specialty do things differently and run their practices differently.

A key challenge for systems with large installation bases is often that the system becomes rigid simply due to the vendor trying to please too many different practices. Customization gets repeatedly delayed or shelved altogether.

Another concern is that when medical records are stored on servers that Medicare can access and control as they please practices may be hesitant to use the system regardless of the benefits to the practices and their patients.

While Medicare’s plan is to offer the software for free, one must ask what free is. Currently, free is software but not training, installation, and ongoing support.

Even if Medicare did make it 100% free, a free EMR is not free if it fails. The costs involved with a failed implementation can far outweigh the costs of purchasing an EMR at market price due to productivity losses, and hardware and implementation costs.

Maybe Medicare could focus more of their resources in the development and promotion of better standards for integrating already proven EMR systems and integrating EMR systems with electronic personal health records, managed by the patient

Why not offer patients a free electronic health record which can easily interface to all the major EMR vendors in the market? Wouldn’t a record they control, that can communicate with all their health providers, and be accessed by any other provider in the event of an emergency be more beneficial?

After all, isn’t the patient’s best interest the goal of healthcare in the 21st century?

—

For more information about EMR Experts, Inc. and their Medical Software solutions, please visit www.emrexperts.com

EMR Market Share

I regularly am asked what the market share of the various EMR companies is. Unfortunately, I think this is an impossible question to answer even if people would love to know the top EMR vendors. EMR vendors just don’t publish the number of EMR implementations they have for strategic purposes (usually). Plus, those that do publish numbers aren’t usually very truthful in the number they give out.

For example, they might say something like they have 500 offices using their EMR. Then, you’ll find out that they’ve actually only sold 20 offices and one of those has 250 actual offices. Then, you’ll find out that the they have 250 offices and plan to implement the EMR in all of those offices, but they’ve only done it in 2 pilot offices right now.

Another example, EMR vendors love to say that they have XXXXXX thousands of doctors using their system. Of course, what they don’t tell you is how many of those thousands of doctors used it once and left it. How many of those doctors only log in to write prescriptions. How many of those doctors only use 10% of the features of the EMR (hardly can be considered using an EMR). We really want to know how many doctors have that EMR, log into it every day and do almost every part of their work in the EMR. Even that’s a hard number to calculate. Should we count them if they print off their scripts or do they have to ePrescribe?

That’s why it’s really brave of Software Advice to try and estimate the EMR market share. No doubt the market share listed is off. I think the most significant number that’s off is likely the list of “Other EMR vendors.” There are 300+ EMR vendors and more being launched every day. I’m pretty sure that this other EMR vendor category actually dwarfs all of the EMR vendors that are on the list.

REC Sharing or Lack Thereof

There was a pretty interesting thread posted to a LinkedIn group about the RECs. Here’s some comments that will make you think a little bit about the RECs and in particular the RECs working together (or not).

It is understandable that REC’s must adapt their programs to the communities they plan on serving….Healthcare is local. However, living in Florida, where there are 4 REC’s, I expect some things to be consistent…for example the implementation process should include the same pre-implementation workflow worksheet. Unfortunately, this may not happen.

We know that ONC is asking that the REC’s play nice and share best practices. However, as a consultant that is talking with 3 of the 4 REC’s about a role….one REC leader in Florida asked me…”Make no mistake, we are competing with the other RECs, so as a consultant, how will you keep our secrets from the other REC’s you are working with in the State? This was a valid question, which I will address in my agreements, however, it made me think. What are they competing for..additional funding that isn’t there yet? Reputation? Most innovative?

Well..I think its all of the above. I believe, the REC, that employs the right people, have the right vendor PARTNERS, and think outside the ONC box, will rise above the rest. However, best practices must be shared and that is where the ONC project lead/coordinators (in Florida its Kelly), must step up and do!

RECs competing is kind of a sad idea for me. Something doesn’t feel right about that. Now take a look at the compensation funding model for the RECs:

The REC’s do get 500k upfront for marketing the REC, initial staffing needs, etc. Then they get $ as they sign up the physcians, in my area its 5k for primary physicians with no EHR. I think they get 3k for primary physicians that have an EHR, but needs to get too MU. Primary Docs are the main targets though. In terms of competing for physicians….they do not. The REC’s are assigned Counties in their State. The only time they would compete is if a doctor has two offices in separate Counties.

With this followup clarification from another user:

In my state, it’s $1500 for sign up, $1500 upon implementation, $1500 for meaningful use. Perhaps the competitiveness referred to in your conversation with the REC in FL relates to future grant awards…

When you see the $ signs in the RECs eyes, now you’ll know why. I appreciate that the government wants to try and reward results. However, something tells me that this isn’t heading down the path the government intended.

An EMR Documentation Wiki

I’ve previously talked about having a HIPAA wiki for your offices HIPAA documentation. I still think that’s genius. However, I’ve extended that idea a lot more into having an offices internal documentation, policies and procedures and any other documentation on a wiki. It just makes sense. It’s the best way to keep things updated and accessible. No, those pile of word documents that people can search isn’t even close to as powerful as a wiki. Even if you have version control and use sharepoint.

Today I started thinking about how every EMR vendor should have an EMR documentation wiki for their software. I know my EMR vendor gave us a manual that was outdated before it could be printed. A paper based manual for EMR should not be useful for you. If it is, then you chose the wrong EMR. You should want an EMR that is innovating, changing and adapting with new technology that they can’t keep their manuals updated.

However, an EMR vendor with some help from their EMR users could create a pretty great wiki that had all sorts of great information that was relevant. I think I’m going to suggest this to my EMR company.

Florida Board Member Recommends Statewide Warning on EMR Errors

Here’s an interesting story from Florida:

A Florida Board of Medicine member wants the board to issue a statewide warning about EMRs, following an incident in which an OB-GYN missed an abnormal Pap smear and blamed the EMR. The OB-GYN punished the EMR by replacing it, while the Board of Medicine punished the OB-GYN with a $20,000 fine, a risk management review, and 100 hours of community service. The board member, a dermatologist, said “”I think the Department of Health needs to put out a warning to physicians that they need to look at their programs’ default settings. This year we have seen as many if not more medical records violations from electronic medical records as we saw from hand-written records violations.”

I’m not sure what benefit the Department of Health issuing a warning would do. I know I’ve never personally seen a warning from the health department (outside of the major news ones). One thing is clear to everyone involved with EMR or not. EMR isn’t the secret potion with no issues. Doctors are still accountable for the care.

Meaning of KLAS Results

I’ve had this post in the hopper since HIMSS back in early March. Unfortunately, it got lost in my other 200 or so draft posts that I work from for future posts. We’ll see if people think I should have left the idea in my drafts or not.

During one my meetings with EMR vendors I discussed the value of KLAS and why this EMR vendor was so HIGH on CCHIT (they’re booth had it plastered all over) and why they chose not to have KLAS ratings plastered beside their CCHIT marketing plan. This really smart EMR vendor marketing manager had previously described the marketing value (note that I didn’t say technical or clinical value) of having the CCHIT certification. So, why not KLAS?

This EMR vendor had obviously done their homework and had considered getting the KLAS rating. The reason they didn’t go that direction was he asked an interesting question of KLAS. He wanted to know how many people actually went to KLAS and downloaded the ratings from their website. Obviously, if they had hundreds of thousands of doctors downloading the ratings from their website, then it could be a great marketing tool for the EMR vendor to sell more product.

Turns out only 5000 people actually downloaded the KLAS ratings. When you add in the EMR vendors and other people who don’t purchase an EMR, that’s such a small footprint. I’ll admit that I’ve seen the KLAS name around a lot of places, but I’ve seen it less and less lately. Does anyone care about KLAS anymore? I’m going to Utah later this month. Maybe I should stop in and say Hi. Seems like there’s such an opportunity in the EMR space right now and they might be missing out.

Lost in Italy for a Bit

Well, as you can see my blog hasn’t gotten much activity lately. I wish I could say that things were going to get better, but the fact is that you probably won’t see many posts from me for the next 2-3 weeks. I’m going to Italy with my wife. I will give you a little look at where we’re headed in Italy.

Rome
We’ll be flying into Rome arriving about 10 AM. We’ll spend most the afternoon going around Rome. I think that Trevi Fountains, and the spanish steps are tops on my list of places to see in Rome. I also love going to St. Peter’s and watching the painters.

Napoli
After touring Rome we’ll hope on a train and head down to my friend’s place in Napoli. She is the sweetest lady. She said she’d have dinner waiting for us and a key to her house so we can just come and go as we please.

The next morning we’ll be touring some of Italy and I definitely have to hit Piazza Garibaldi to get me a suit and some other Sunday clothes for church. I was also told that there will be a baptism Saturday night. This happened last time I went to Napoli (truthfully Pozzuoli). It’s so much fun, because I get a chance to see a bunch of the members all at once. The next morning I’m sure we’ll enjoy church in probably the most beautiful chapel I’ve ever seen. Well, at least the view from the chapel is the best.

Amalfi
Monday we’ve got a nice hotel lined up in the beautiful town of Amalfi. We’ll probably check in to our hotel as early as possible and then head up for a little hike to the waterfalls just above Amalfi where they use to make paper. It’s an incredible hike that feels like you’ve gone into a completely different world. Got to love Valle Dei Mullini.

Positano
After spending the night in Amalfi, we’ll be taking an early morning “chicken bus” up to my favorite place in Italia:Sentiero degli Dei(Trail of the Gods). It’s about a 4 and a half hour hike. At the end of the hike there are 1000 steps to reach the beautiful city of Positano below. We’ve got a hotel lined up in Positano which will be a certainly welcome relief.

Napoli – Pompeii and Vesuvius
The next morning we haven’t decided exactly what we’ll do, but we’re considering heading to Pompeii since it’s in the area. However, if we’re too tired we might head back to Napoli and go to Pompeii later. I would love to take the boat from Positano back to Napoli. The boat is a lot of fun and a nice soothing ride.

Venice
After spending a couple days with friends in Napoli, we’ll be heading for a romantic weekend in Venice. I can’t say anything about Venice. It’s absolutely the most unique place I’ve ever been. It’s Romantic. It’s incredible and I can’t wait to stroll the streets with my wife. Not to mention a nice gondola ride.

Bologna
I’ll be meeting a friend of mine in Bologna. We’ll be attending church in Bologna which should be interesting since we’ve never been there. I’d rather go to church somewhere else, but I really want to see my friend Maria Rosaria so we’ll do what we have to do. Sunday after church my friend will pick us up and after eating some of her mother’s fine fine Italian cooking we’ll be heading to Florence.

Florence
We haven’t decided how many days we should spend in Florence. We’ll stay at least a day and up to 4 days. I must admit that my wife and I aren’t that into art and so I’m not sure how long we’ll want to stay in Florence. I think we’re probably going to want to head back to Napoli to spend more time with friends.

Well, that’s the general round up of our trip through Italy. Most things are subject to change, but it doesn’t really matter. No matter where we go or what we do we have nothing to worry about, because the best part of Italy is….

THE FOOD!!

Hopefully I’ll be able to at least blog a little from Italy, but if I can’t then we’ll see you after our trip.

Benefits of EMR Software to Consumers

One of my readers emailed me about a presentation he was looking at doing about EMR software and consumers. I was really intrigued by the idea of presenting on the benefits of an EMR to the consumer (Translation: Patients). I’d spent quite a bit of time thinking about the benefits of an EMR to doctors, but I hadn’t put as much thought and effort into the benefits of an EMR to patients.

Here’s our initial brainstorm on the benefits of an EMR to patients. Feel free to add to the list in the comments:
-Online Appt Scheduling
-Online Prescription Refills
-Online Patient Information
-Online Forms (possibly pulled in from a PHR)
-e-Visits (this is a controversial one)
-Secure communication with doctor
-Recall/Reminders Electronically
-Patient participation in health record (ie. diet journals)
-Better point of care
-Clinical decision support
-Better access to your health records
-Less errors
-Lower cost
-Better collaboration and communication between primary care and specialty Drs

No doubt some of these benefits should have a ? mark by them. Although, I like the idea of looking at the EMR from the patient perspective. I do after all think that consumers might be the key to “forcing” broad EMR adoption.

EMR Permissions

It’s always interesting to talk with someone about the permissions they should set in their EMR. Pretty much every EMR that has any footprint has a broad set of permissions available to restrict the access of your end users. It can often be a pretty significant task to set all of these permissions. Thankfully, it’s a project that you do once and then don’t have to go again (except for maybe some minor changes). Also, many EMR vendors have good templates for giving you a starting point for permissions.

What usually happens is that users end up with ALL sorts of restrictions on user accounts. I can’t say this is such a bad thing. Users should only have access to the information and features they need for the job. However, in the application of this rule, people almost always go overboard. Shortly after an implementation, the permissions are eventually opened up.

Since this is bound to happen, it’s important to make this part of the EMR implementation plan. Don’t make your nursing staff beg you for access to something. Give them a way to ask for access without making them feel like they are doing something they shouldn’t. Instead, encourage them to ask you for access to things that would make their life easier. That doesn’t mean that you’ll always give access, but from what I’ve seen, most people don’t want more access than what they need.

Remember that the rule is that people should only have access to the information that they need. If they’re asking for access to certain information to make their (and often your) life easier, then they probably do need it and should have access.

EMR Question and Answer: Domain Controlled Networks

I got the following question from Brandon about the need to have a domain controlled network in order to comply with HIPAA.

I am currently trying to implement an EMR system in a small practice. I am trying to convince the parties involved that it is necessary to transition to a domain controlled network for security reasons even though this type of network is not required for our EMR system or its server. My understanding of HIPAA is that simply having a firewall does not qualify as a “secured network”. Am I right on this?

Brandon,
You are correct that just having a firewall does not likely qualify as a “secured network.” However, that doesn’t necessarily mean that you need to have a domain controlled network to meet the HIPAA security standards. You could still manually apply the domain security policies on to individual computers and achieve the same level of security.

Of course, the key word in that statement is the word “manually.” If you have less than 10 computers, then this probably isn’t a huge deal and can be done manually. Once you pass 10 computers (or somewhere in that range) you probably want to consider using active directory to manage the security policies on your computers. It’s much easier to apply policies on a large number of computers using active directory. Plus, you can know that the policy was applied consistently across your network.

You also shouldn’t ignore the other benefits of a domain controlled network. I’ve written previously about the benefits of things likeshared drives as a nice companion to an EMR. Active Directory makes adding these shared drives trivial. It’s also a nice benefit to have a universal login that’s managed by the domain and can work on every computer in the office.

Plus, if your EMR runs on SQL Server and you buy a nice but inexpensive server with Windows Small Business Server, then you already have the software for active directory. So, it’s really an easy decision to use it. I’ve implemented it at a site with 5 computers and it’s been a great thing to have even if it’s a bit of overkill.

New Healthcare Blog Announcement I Received

Ingenix today announced the launch of “The Leary Report on PPS,” an interactive blog designed to help facilitate discussions about the important changes taking place in Medicare reimbursement.

“The Leary Report on PPS” is dedicated to discussing Prospective Payment System (PPS) issues, intially focusing on the severity-adjusted reimbursement changes proposed by the Centers for Medicare & Medicaid Services (CMS). CMS intends to implement a new method for classifying patients for inpatient reimbursement based on a severity-adjusted DRG model that will modify CMS’ existing Inpatient Prospective Payment System (IPPS), allowing Medicare to pay hospitals for inpatient services based on the severity of a patient’s condition.

“The industry’s input is needed because CMS has yet to finalize many details of its severity-adjustment system,” said Robert J. Leary, vice president of Ingenix. ” ‘The Leary Report on PPS’ provides a dedicated forum where industry professionals can collaborate among peers, evaluate alternative ideas and formulate feedback that will help CMS shape the final details governing how hospitals and other organizations are paid for services.”

The above is the “press release” I got a while ago. I just checked the blog and it hasn’t been updated since October 9, 2006. All I can say is that it isn’t easy to keep a good blog going. It takes commitment and passion. I will say that it is a good idea to interact in a community of bloggers. HITSphere is the best one I know for Healthcare IT bloggers.

On a personal note, my wife is due with our second child on Wednesday. Don’t be surprised if I’m not on here for a while.