Implementing EHRs/EMRs

A few days ago we received this email:

In the past few years our federally funded research floor had to be taken off of an electronic record system. We returned to paper charting. We had to develop a new system of charting using forms that we made up as we went along. We have no way to interface with the various labs throughout our hospital and clinic. Charts have to be copied so that the Medical Records Department in our hospital has a copy. Copies of the research results must be made for the various Principal Investigators and their subordinates. We used to be able to copy patients’ lab results so they could give this information to their physicians,we no longer have this capability. We have had to abort studies because lab results were found not be WNL. These studies would never have been started if the nurses had the capability of checking results before starting studies. If 1 of our patients had to be admitted to the hospital, the hospital would not be able to access this patients records from his stay on our division.
I cannot begin to tell you how the loss of EMRs has adversely impacted our work. Please keep up the good work with helping people implement EMRs.

Sincerely,
A Midwest RN

This email got me thinking, as often as I hear people complain about going on an EHR and I really don’t think they would trade it for paper once live. I thought I should ask our readers.

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One of the doctor’s we work with forwarded us this neat article from the Economist that has a good overview of HIT across the globe. Its pretty similar to a bunch of stories that have been in the paper lately, except for this great little graph of EHR dollars over the years. Its the strongest graphical representation of the exponential increase in HIT dollars over the next decade. I liken the HIT industry to a snail with a jet pack strapped to its back… whether or not its headed for a brick wall is up to you.

On a related note, I continue to be amazed at the difference that President Obama and the ARRA / HITECH stimulus have made on physicians’ interest in EHRs. On projects that we’re working on, I no longer hear providers questioning the need for an EHR or whether their practice will eventually go electronic. A physician champion I work with said it best… when environments change, animals will move, adapt, or die . Now that the clinical environment is changing, physicians similarly decide whether to move (which won’t work because an EHR will catch up to them sooner or later), adapt, or die (er.. I mean retire).

Today I attended California’s NextGen Advocacy Group Meeting in Southern California where Jan Lee, MD spoke about where the NextGen KBM/templates are going. I thought I would share what I learned.

5.5.28 will (should) have a KBM Upgrade Wizard in it that will help clients do their own KBM Upgrades. I wasn’t very happy with the fact NextGen took this right away from clients, so I am happy to see that it is returning! I can’t wait to see what this wizard looks like.

KBM 7.8

• Meets CCHIT requirements
• Should enter LGR this week
• VAERS reporting
• Well Woman Quick Visit
• New Gyn Home Page & Tabbed Visit
• 3 Gyn Quick Visits
• NextMD Templates
• Custom plan enhancements
• Age specific Peds Physical Exam with Quick Save
• Review co-sign orders
• Procedure scheduling
• Pre-procedure patient instructions
• Advanced directives enhancements
• EtOH/Drug detox
• PT Exercise Template
• Physical Exam comments – option to carry forward

KBM 7.9 (Hopefully)

• Orders table rewrite!!!!!!!! (I’m excited)
• Document formatting options
• Health Maintenance/Disease Management
• Specialty commitments
• Primary care (new HPIs & better documentation of chronic disease)
• Billing & immunization updates
• Ease of use enhancements

KBM 7.9 Primary Care Enhancements (Hopefully)

• HPI Templates – Acute Fatigue, Chronic CAD, CHF, Asthma
• Well Man, Welcome to Medicare, & CAD Quick Visit Templates
• Create specialty specific ROS pop-ups
• Improve nursing workflow

A couple of other things that they mentioned with full disclosure that they may not happen and not tied to a release:

• The ability to lock documents so encounter locking may not be needed
• The ability to hide/show the Left Hand Navigation Bar
• Specialty specific Physical Exam template
• Diagnosis specific order sets

One of the hottest blog topics of late 2008 / early 2009 has been the cries of smaller EHR vendors that innovation is stifled by large EHR vendors and CCHIT. I’ll agree that some aspects of CCHIT are disconcerting, particularly the focus on ratcheting up functionality requirements that are largely irrelevant to the goals of improving patient care, EHR usability, and connectivity. However, the EHR market is clearly over-saturated with a tremendous list of EHR vendors . Having a quality product put together by a genius doctor, who used to be a programmer, is no longer enough. At this point, smaller EHR vendors need to be disruptive to capture market share; doing so will put the smaller vendors in the driver’s seat and make larger vendors sit up and take notice.

Three EHR vendors that are clearly disruptive, and are making the big boys take notice, are:

1. Practice Fusion with their free, web-based, patient driven EHR.
2. UShealthrecord (I know, I still owe you an article on them) with their Silverlight web-based and integrated EHR/PHR/HIE of the future.
3. Surgimate’s surgery-specific solution
4. One of our clients (I need to get permission to use their name), who is a billing software and managed services company, is offering a free EHR that they just “throw in” with purchase of their other services.

Yes, the large EHR vendors have money, an army of sales people, and huge booths at trade shows. But these large vendors got to where they are by putting together industry leading products. The smaller EHR vendors of today have the same opportunity to grow into large vendors by being disruptive, with the added benefit that the large vendors have already paved the way.

While this post may sound somewhat harsh, it comes from personal experience. TempDev is a small EHR consulting firm playing in the sand box of some of the largest consulting firms in the world. The list of EHR consulting companies is much, much, much longer than that of EHR vendors, with new players joining the market on a daily basis. In the NextGen-realm alone, I have a list of 34 consulting companies that we’ve run across that. However, by being disruptive and focusing on optimization rather than the classic consulting go-tos of strategic planning, implementation, and training, we have created our own niche market.

We have created our new brochure and we wanted share it with our blog readers first. We hope you enjoy it!

Phil Miller is a Professor of Biostatistics at Washington University School of Medicine who has been involved in large, multi-site NIH sponsored clinical trials. He teaches courses in epidemiology, biostatistics, and research design and is also the leader of the Research and Design Group at the Institute for Clinical and Translational Sciences (ICTS) at Washington University. We often have many conversations about the possibilities of all the wonderful discrete data just sitting, waiting to be mined in EMRs. So I asked him to write a blog for us and in the interest of disclosure, he is also my father.

EMRs and Research

One of the potential benefits of having an EMR is to facilitate medical research. This is particularly true when the data is entered into systems which contain mostly discrete data elements rather than simple electronic copies of printed reports or consist of substantial amounts of free text, e.g. transcribed dictations. While the promises are clear, the barriers are frequently inadequately addressed. Some of the significant issues that remain to be adequately addressed are:

EMRs are not integrated with clinical research data collection systems: Most large scale clinical trials, particularly those sponsored by the pharmaceutical industry do not provide ways to avoid printing out of the EMR, thus creating a shadow chart. The information is then abstracted by hand and re-keyed into the research system. This avoids the potential savings in personnel effort with wasteful duplication of effort. When site monitors arrive to audit the data, if the information has not been printed out, then there often becomes a tricky policy issue of how they are granted access to the source documents in order to conduct the audit. As standards for EMRs emerge, the research industry may be prepared to make the investments to be able to automatically extract the needed information.

EMRs are not conformant with research standards: The design of most EMR systems is to facilitate clinical care. In the research enterprise, there is strong commitment to adhere to standards for data elements. In corporate sponsored research there may be corporate standards. For studies which are regulated by the FDA, CDISC is the preferred standards. In other environments HL7 is the common standard. While IT folks can often provide the necessary syntactic conformance to the standard, for the research community the semantic conformance is much more important – for each data element, are the codings done with the same definitions for each of the data elements for every facility?

Regulatory requirements: While mining a database for quality improvement or other operational tasks is allowed under HIPAA, other considerations arise when conducting research. Most medical journals require (and any research conducted in an institution which receives federal research funding mandates) that the research is approved by an Institutional Review Board (IRB) to protect the rights and welfare of the subjects. An important issue is whether the patient, whose data is contained within an EMR has given consent for the use of their data for research purposes. In addition, in extracting data from EMRs there may be a need to scrub personal identifiers from the data to conform to good clinical research practices and HIPAA’s “minimum necessary” rule.

With the exception of a few academic research centers and large practice plans, the promise of EMRs to facilitate research has not fulfilled its promise. The barriers mentioned above frequently are too expensive for most practices and hospitals to solve just in order to facilitate a research agenda.

HIMSS09 was action-packed and full of excitement. Despite organizations hurting from the economy, there was a sense of hope and rejuvenation.

The debate over EHRs seems to have been decided. The tone of the conference was “If you aren’t on an EHR now, you’re behind the times and better get on one as soon as absolutely possible”. The focus is now on what’s next: HIEs, PHRs, and meaningful use.

Some of the highlights were:

• CCHIT’s willingness to answer to their critics
• ushealthrecord and their Silverlight web-based EHR/PHR/HIE of the future
• Several great sessions on the stimulus (here, here, and here)
• The CEO of Kaiser proclaiming “Reform now, damn it!”
• The increased focus on CHCs and the Safety Net
• Success in HIEs

We laughed, we cried (tears of joy when NextGen’s iPhone app was announced), and we froze… this California boy is firmly against conferences in the North before June. Thank goodness HIMSS is in Atlanta next year! But Chicago is a beautiful city and McCormick Hall, while enormous, was a fitting home for such a non-stop week.

I have lots and lots of to dos, including expanding on items that I was able to only briefly report during the conference. Keep checking back for in-depth posts on the more exciting topics….after I have a few days of rest!

Today NextGen announced that they have created a NextGen App for the iPhone. I can’t begin to describe how exciting this is and how cool it will look in demos. I have to confess that Ben got a sneak peak at it last night and was drooling over it.

Some of the features it will include:

• Access to individual patient records
• Medication and allergy information, and e-prescribing
• Lab orders and results, including workflow capabilities
• Problem and procedure lists
• Image and document access
• Task management and access to the appointment schedule

Thank you NextGen! This will be awesome!

For the final education session of HIMSS09, I attended a session entitled “Developing a Plan to Operationalize the Results of the Economic Stimulus”. The session was led by Bruce Fried and Lauren Mack, both health care attorneys with Sonnenschein.

Fried started off by stating that the current ARRA/HITECH monies are just a down payment and he believes that the regular budget will include additional monies. He also speculated that the health care model in the United States will become increasingly focused on Accountable Care Organizations, although this brings up Stark and anti-trust concerns.

Mack started off by explaining that “meaningful use” is not static, rater CMS has been instructed to continue to refine and expand meaningful use to improve quality of care. The path and process for this is currently undefined. Furthermore, organizations that have a distributed system whereby multiple platforms are used in conjunction with an EHR application need to be careful to ensure that these ancillary systems are certified as well if they’re determined to be part of the overall “meaningful use” solution.

To prepare an organization, a committee similar to the HIPAA committees of that movement should be formed. This group should be charged with the following responsibilities:

1. Determining the path and timing of the EHR solution to meet the stimulus deadlines.
2. Educating all areas of the organization about the opportunities and requirements.
3. Review the regulations to ensure the EHR solution qualifies.
4. Performing audis to ensure that the meaningful use required functionality is actually being used (eg e-prescribing could be deployed, but are the physicians actually using it?)
5. Watching the HIE provisions carefully for further definition and working with community partners and local HIEs/RHIOs/Registries to understand what has been done to date. When the HIE provisions are defined, there will be little time to execute.
6. Beginning quality reporting on the current clinical quality measures, with an eye towards expanding the quality reporting upon the possible expansion of these measures.

Mack also provided some specific suggestions for the demonstration requirements of the act:

• An attestation
• Submission of claims with statistics codes (although in a conversation with an ONC representative, I was informed that CMS is trying to avoid this approach)
• A survey response
• Reporting on clinical measure

This session did the best job of detailing what steps can be taken now to prepare of the stimulus. This should be required reading for anyone involved in moving their organizations’ EHR efforts forward.

The fourth and final day of HIMSS09. This morning’s keynote speaker was former Fed Chairman Alan Greenspan. I assume HIMSS booked Greenspan well before the current economic crisis. His bio in the conference guide reads like a thesis on the causes of the crisis:

Dr. Greenspan has advised leaders across the political spectrum as he called for a smaller federal budget deficit, freer trade, and less government involvement in the economy…

However, I studied Business Economics in school, so I eagerly awaited Greenspan’s speech.

Greenspan explained that growing medical costs have had little effect on the economy, despite those medical costs growing at a rate of 2% of GDP, because of the continued growth of the economy. However, the current financial crisis and the upcoming slow recovery will produce a clash of resources that will require the issue to be dealt with. The growth of medical costs is a combination both of the coming retirement of the baby boomers and the increasing availability of advanced medical services.

The current economic crisis is purely financial in cause and Greenspan remarked that non-financial sector balance sheets were healthy prior to the crisis. The freeze of short term credit caused a huge back-up of inventory, which resulted in the seizing of the manufacturing sector. This is beginning to turn around as inventories are drawn down, but the economy will not begin to recover until housing prices stabilize. Greenspan predicts this occurring in the next few months.

Greenspan also discussed entitlements costs, particularly in our current situation where known future entitlements cannot be covered. He advocated creating a coinsurance model based on income that would essentially preclude affluent citizens from entitlements altogether.