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Doing it Right

by Rob on March 18, 2009 · Comments

in EMR

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Electronic Medical Records are coming.  The economic stimulus bill (furious spinning kittens notwithstanding) assured this.

Under the terms of the bill, CMS will offer incentives to medical practices that adopt and use electronic medical records technology. Beginning in 2011, physicians will get $44,000 to $64,000 over five years for implementing and using a certified EMR. The Congressional Budget Office projects that such incentives will push up to 90 percent of U.S. physicians to use EMRs over the next 10 years.

Practices that don’t adopt CCHIT-certified EMR systems by 2014 will have their Medicare reimbursement rates cut by up to 3 percent beginning in 2015.

(From Fierce Health IT)

There will be even more money for implementation.  We look forward to our checks (and are not counting on them yet).

Now it is time for the flies to start gathering.  Wherever there is lots of money, “experts” pop up and new products become available that hope to cash in.  Doctors, who are never lauded for their business acumen, will be especially susceptible to hucksters pushing their wares.  It seems from the outside to be an simple thing: put medical records on computers and watch the cash fly in.

Anyone who has implemented EMR, however, can attest that the use of the word “simple” is a dead giveaway that the person uttering the word in relation to EMR is either totally clueless or running a scam.  It’s like saying “easy solution to the Mideast unrest,”  “obvious way to bring world peace,” or “makes exercise easy and fun.”

Run away quickly when you hear this type of thing.

Just like becoming a doctor is a long-term arduous process, EMR implementation happens with time, planning, and effort.  It’s not impossible to become a doctor, but it isn’t easy.  With EMR adoption, the most important factor in success is the implementation process.  A poorly implemented EMR isn’t simply non-functional, it makes medical practice harder.  A well implemented EMR doesn’t just function, it improves quality and profitability.

How do I know?  Our practice ranks very high for quality (NCQA certified for diabetes, physicians are consistently ranked high for quality by insurers), and we out-earn 95% of other primary care physicians.  EMR allows us to practice good medicine in a manner that is much more efficient.

So how’s a doc to know who to trust?  What product should he/she buy and whose advice about implementation should they follow?  There are many resources out there.  Here are a few I think are especially worthwhile:

  1. Buy a product that is certified by Certification Commission for Health Information Technology. CCHIT is a government task force established to set standards for EMR products. Its goal is to allow systems to communicate with each other and enable more interfaces in the future.  The bonuses for docs on EMR are contingent on the system being CCHIT certified (think of it as something like the WiFi standard).
  2. The American Academy of Family Physicians’ Center for Health Information Technology and the American College of Physicians both have tools to help member physicians decide on an EMR. Your own specialty society may, too.
  3. Several professional IT organizations have programs to improve EMR adoption, including HIMSS and TEPR.
  4. Austin Merritt has written a good article of advice on his website Software Advice that underlines the importance of implementation.

The best advice I can give, however, is to visit a doctor’s office who is using an EMR successfully.  This office should be as close in make-up to your office as is possible.  You should be able to look at how they do it and see yourself in that situation.  Never buy a product before visiting at least one office like this (no matter how good the sales pitch).  When you visit, make sure you ask them about the implementation process.  How did they do it and how hard was it?

Which EMR do I recommend?  Remember, I have been on EMR for over 12 years, so haven’t had much of a chance to shop around.  You hear raves and horror stories with every product.  Here is some basic advice:

  • Get a solid CCHIT-approved brand that has been around for a while
  • Don’t pay as much attention to price as you do function.  Since the EMR will be absolutely central to the function of your office, it is a dumb mistake to overly-emphasize cost.
  • Realize you are paying for a company, not just a product.  It is not like buying a car, it is more like having a child or getting married.  REALLY research that side of things.  A good EMR with a bad company behind it should be avoided like the plague.
  • See how connected the user-base is as well.  A solid user group will do much to make up any deficiencies in the product and/or company.

So much time is spent shopping over EMR products, but buying an EMR is like being accepted into Medical School; your work is just beginning.  That’s OK, because like medical school, the effort put in gives a very worthwhile product.

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  • Ken O
    Well, Dr Rob has got my point; I meant talk to the whole staff (or at least representatives of all main functions that you, and not the practice you're visiting or the sales rep, choose).
    I've diagnosed a flakey, underspecified and overloaded server and network within 5 minutes of arriving in a hospital for an outpatient visit, simply by chatting with the clinic receptionist (and she was known as the "Dragon Lady")! Ok, this is my specialty, but if I can do that that quick, a proper "due dilligence" visit should expose a bad system.
  • S Silverstein MD
    I didn't make the point before, but I consider site visits - in the plural - an essential due diligence before an investment of this magnitude. However, one must be diligent while exercising the due diligence.

    I've given dog-and-pony shows myself as a key site for a vendor, and was under some subtle pressures not to show the warts.

    Ask tough questions on the site visit, as if your patients' lives and your career depended on it.

    Because they do.

    -- SS
  • Rob
    The answer is somewhere in between. Yes, there is abuse and you need to be suspicious, but a physician coming to another physician's office and talking to the staff is unlikely to be duped. Watching the process and talking to the whole staff - you get a good picture of things. Be wary, but not going to site visits limits you to the opinions of salespeople. You know that salespeople aren't going to tell you anything bad.
  • S Silverstein MD
    Mr Silverstein, I’m sure what you say is correct in some cases, but if a system does not work stablely and reliably, a site visit, and informal chat with someone like Medrecgal. will reveal the fact unless, not only the partners, but the entire staff of the site are being paid off.

    As a former CMIO of a 1000+ bed healthcare system, I only wish it were so easy. Sometimes it takes a bit more to assess and fix a system. link
  • Ken O
    Mr Silverstein, I'm sure what you say is correct in some cases, but if a system does not work stablely and reliably, a site visit, and informal chat with someone like Medrecgal. will reveal the fact unless, not only the partners, but the entire staff of the site are being paid off.

    Also I'd rather change my work practices a bit to use a reliable product, than buy an unreliable and unsupportable customisation.
  • You assume your efforts are completely portable in the real world in a short time frame.
  • Rob
    Yes, Ken. The single best argument about those who nay-say about EMR is my office and others like it.
  • Just beware conflicts of interest when seeing someone else's EMR.

    Think this doesn't happen? In pharma it happens. See for example yesterday's NYT article "Drug Maker Told Studies Would Aid It, Papers Say" at http://www.nytimes.com/2009/03/20/us/20psych.ht...

    Regarding clinical IT, per Jonathan Bertman as I posted at http://www.ischool.drexel.edu/faculty/ssilverst...

    "Clearly—and reasonably—an EHR company would try to avoid giving you the contact information of an unhappy client. But might the doctor to whom you are referred be getting compensated? Surprisingly, a number of EHR companies actually pay referring physicians to "compensate them for their time" in speaking with you. This can take the form of a direct cash payment or free/discounted software and services. Again, this is not necessarily unreasonable so long as the relationship is disclosed. "
  • Ken O
    I'd agree Rob, and not just about EMR products. If I was wanting to buy any software that requires this degree of specialisation (so not ledger accounting but possibly cost accounting), say configuration control systems, I'd want to see the product in action. If nothing else, the mere fact that an existing customer is prepared to let other people see the product in action is positive.
  • Rob
    Atul: I really would not trust a salesperson to show the product to invest in. I would be highly suspicious if they could not produce a practice that is already doing what you need to do. Our office has been open for this and because they see us actually using it (no smoke and mirrors) they see it is not a gimmick or sales-pitch. The product really works. Not having that is taking a big risk based on incomplete information.
  • Rob
    OK. Let me see what I can do. I happen to personally know several of the commissioners on the CCHIT. I'll see if I can get more detailed info.
  • Bah - I hope this doesn't double post. I typed out a comment on my experience with EMR and the "transition" that ended up being a novel, so I sent it over to my blog instead. Give it a read if you'd like!

    Great post. Wonderful advice - as usual.

    Hope
  • S Silverstein
    CCHIT is a private organization that secured a government contract a year after formation They are not "quasi governmental" as would be, say, a municipal transit authority.
  • Rob, A great, balanced post.

    CCHIT is a quasi-governmental for sure but recently there has been some call at taking a closer look: Some folks from HIMSS and AHIMA and other are also occupying board-level seats at CCHIT, causing concern about conflict-of-interest, per Healthcare IT News. The fee structure for CCHIT is also a big road block fro smaller players and merits a fresh review.

    Going back to the main topic of the post, I have dabbled in EMR's for a few years and agree with your recommendations. However, I think that it may be unrealistic to " visit a doctor's office who is using EMR successfully". In my guidance to the physicians, I include this as a desirable step but not necessarily a deal-closer or a deal-breaker.
  • S Silverstein
    (the term "with a mandate" means "with a purpose".)
  • S Silverstein
    CCHIT was mandated by the U.S. government? Do you have a reference?

    In "Finding a Cure: The Case for Regulation And Oversight of Electronic Health Records Systems" by Hoffman and Podgurski, Harvard Journal of Law & Technology 2008 vol. 22, No. 1, it states specifically on p. 132:

    CCHIT, a private-sector organization, was created in 2004 and is composed of three HIT industry organizations: AHIMA, HIMSS and NAHIT. HHS awarded CCHIT a three year contract in Sept. 2005 with a mandate to develop certification criteria and an inspection procedure for EHR systems."

    This would make CCHIT a private firm that is a contractor to government, and became a contractor after formation, not mandated.
  • Rob
    CCHIT was mandated by the government. It is officially non-government, but the commissioners are made up of public and private segment people. The EMR products (see above) must be CCHIT certified.

    I guess the best term to use is "Government Sanctioned."
  • S Silverstein
    CCHIT is a government entity? How is that possible, as its registration is as a non profit 501 (c) (3)?
  • Rob
    CCHIT came out of Bush's Medicare Modernization Act - it is a government entity with various representations on the board. Mark Levitt is the chairman - former CEO of an EMR vendor, then worked for HIMSS for several years. Quit that to chair CCHIT. The board has some government, some industry, and some medical people on it. It is a real entity that the EMR vendors are trying to keep up with.

    The goal of CCHIT was to make a standard when the term "EMR" was used and to make a standard that they can reimburse for (or penalize for not having). Otherwise, any company could make an EMR-Like product and put it in an office.

    The standards started broadly and are becoming increasingly stringent over time, with the ultimate goal being a medical record in one being completely portable to another (either over the Web or on a flash drive).
  • I agree, with one caveat: CCHIT.

    I would like to know how CCHIT functions differently from a fictional "Drug Certification Commission." Imagine such a Commission founded by PhRMA and other pharmaceutical industry advocates, partly staffed at high levels by pharmaceutical executives, and "certifying" drugs for consumer purchase simply on the basis of their being manufactured under cGMP guidelines (current good manufacturing processes). Imagine this Commission declaring drugs "certified" without clinical trials, impartial regulatory oversight, postmarketing surveillance and in the face of equivocal studies and outright unfavorable studies showing increased risk of adverse events. How is CCHIT different from this fictional drug commission?
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