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It’s Not About Meaningful Use …

MucartoonWith the impending comment deadline for Meaningful Use (MU) fast approaching, many organizations, from CHIME to AHA to AAFP and others are asking for some form of relaxation of MU criteria in the final version.  Now it is not to say these concerns are not justified, it just may be that they are misplaced for the vast majority of those who currently do not use an EHR, small physician practices and clinics.  It is within these small practices, which are really just small businesses, that the majority of patient care occurs and where possibly the biggest benefit may be derived in the use of EHRs. It is also here where we may find the highest adoption hurdles, and those adoption hurdles are not so much about MU criteria, but more about productivity losses in adopting an EHR.

This past weekend I spent some time with a nurse who works in a primary care/pediatrics clinic in Vermont.  There facility, part of a network of several clinics, recently adopted and went live with a new EHR system (about 18 months ago). According to the nurse, this EHR, from one of the big names in ambulatory systems, has been a complete disaster for the clinic.  Productivity is way down, countless glitches have occurred, whole system crashed during a recent upgrade and the list goes on.  For 2009, this clinic, which has been in operation for a few decades, had its first ever loss last year, the year they went live with this EHR. The clinic puts the blame squarely on the EHR, which has severely constricted their ability to see patients and as all readers know, clinicians get paid for seeing patients, not trying to use a complex and difficult to use EHR.

It is stories like this that concern me.

This is a clinic trying to do the right thing, trying to use an EHR in a meaningful way (note, did not say meaningful use) and they are struggling. Yes, they do want to deliver the best patient care, but at the end of the day, they, like any business have bills to pay.  They are losing money far in excess of what HITECH Act incentives will provide. This story is, unfortunately, not unique, though few EHR vendors will come clean on the productivity hit to a practice.  Maybe instead of guaranteeing that their application(s) will meet MU criteria, EHR vendors should guarantee that the productivity hit of using their solution will not exceed HITECH incentive payments.  Now that would be an interesting value proposition.

Thanks to Michael Jahn of Jahn & Associates for the MU cartoon.

John Moore is an IT Analyst at Chilmark Research, where this post was first published.

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  1. The subpoena named Blagojevich Obama is something to be expected as the President is asked to testify for the trial of former governor Blagojevich. It was due to the news that Blagojevich was attempting to sell the President’s empty senate seat, without the President’s awareness but rumored to have communications with Blagojevich about the seat. Obama’s still the President of the United States of The US; even if he is subpoenaed to witness on the trial, the challenge that he’d be able to do it is almost none.

  2. Start over. Re-examine what works, and proceed from there. You can’t have a rational discussion when someone hangs an ideological statement on every word. You also have to separate the good faith commentary on how to improve existing systems versus debates about whether they should be imposed on private businesses, etc. One can assume the latter comments are not building toward the same enterprise.
    A main issue with practices trying to implement these systems is communication/expectation. And again, every one of the discussants leaves out patients and patient access/ease of use as a factor in chasing profits. That’s like redesigning cars but not consulting drivers about innovation.

  3. For those who are not computer addicts, have you met some of these people who proclaim how the silicon universe will save us time, money, and energy, and make us better people? I for one walk away from these interactions and wonder what planet they came from to truly believe this crap!
    It’s just another money scam in the end, and the defenders and apologists do not want you to know this. Just watch the attack that will proceed after this comment.
    Electronic records have some positive place, I will admit that. But, just use this as an analogy:
    Gone to a commercial business of late to purchase something, and it is not on the computer screen, and then watch how it takes 2 or 3 people to wind up problem solving the issue, when the price was on the product from moment one? And the system can’t ring it up as it is not keyed in? Individuality is lost per the silicon age, and in medicine, that is the hallmark of the system, individuality. A word few IT freaks can say, much less understand.
    And that is what you want the coming health care deform to provide for you? Think about it!

  4. Does anybody know if the free ONC government cheese program is distributing free purple shrouds with every EHR? Are these shrouds “certified”?
    I would suggest they keep the shrouds, but in the tradition of Dr. Kellogg, substitute yogurt for the cheese.
    Wearing the purple shroud in public makes a statement: I’m impacted with EHRs–hence the yogurt cultures.

  5. Translating Dr. Halamka’s words above, to the buzz on main street, what he said was, “DRINK THE KOOL-AID.”
    Then go shopping for your purple shroud.
    Beam me up, Scottie…

  6. Halamka states: “My advice – trust the ONC folks and Federal Advisory Committees. Join the process. Be open about your opinions. Feel free to disagree with any idea or policy. ”
    Of course,he expects us to believe him, especially when HIT vendor shills and HIMSS insiders are holding influential positions, providing educational resources to the lawmakers. Give me a break.

  7. “monitor these tools for their impact on safety”
    Dear Dr. Kibbe,
    Actually, it is whether these tools are safe from the getgo. Since when is it legal to sell medical devices without FDA approval?

  8. For all, a clarification on my own position vis a vis EHR technology and safety: it’s very, very important to monitor these tools for their impact on safety. This has been almost completely overlooked for a generation, but I think that is about to end. If we (that is, our government) regulate EHR technology with respect to its compliance with specific standards for messaging and exchange, then we must also consider that it is appropriate to regulate the technology with respect to its effects on safety and errors. This is coming, as the passion and eloquence of some commenters here suggest it should, and I strongly believe that it’s a good thing that it does come.
    Kind regards, DCK

  9. If the people in this forum knew what it is like to participate in all these committees to support and promote the health care IT interoperability standards they wouldn’t speak so negatively about it.
    I spend my nights and weekends with the spirit of contribution to a cause. Time that I should be devoting to my family and myself.
    How disappointing it is to have to read such slanderous statements of some great contributors.
    The EHR Guy

  10. Good point, e-dollar Bill! If you look at the caption under Blackford Middleton’s photo in the WaPo article, it says “courtesy of HIMSS”. And why is that? Because Middleton was HIMSS Chair in 2006!
    In the WaPo article, HIMSS worked closely with technology vendors. That is HIMSS EHRVA!
    “With financial backing from the industry, they started advocacy groups, generated research to show the potential for massive savings and met routinely with lawmakers and other government officials.”
    HIMSS Advocacy/Lobbyist office is located in the Beltway. The research HIMSS generated came from HIMSS Analytics! HIMSS EHRVA has the big HIT companies as its members, who provided financial backing for HIMSS (Cerner, GE, Siemens, McKesson, etc).
    Read the link below from HIMSS’ own website. My comments are in parenthesis:
    http://www.himss.org/ASP/about_FAQ.asp
    “What percentage of HIMSS’ revenues come from vendor firms?
    A SIGNIFICANT portion of HIMSS’ revenue comes from vendor and consulting firms. Those funds, however, are used to create education, tools, and resources by and for our members (advocacy, lobbying). In the past year, HIMSS has published more than 200 new resources and hosted multiple education programs, both nationally and regionally through our chapters.” (also used grants and tax-exempt status to host international conferences, which includes the MidEast, when there is less than 12% adoption in the U.S.)
    One way to look at it, Margalit, is that everyone in government is somehow connected to HIMSS. Have you ever heard the phrase “Six Degrees of Separation”?
    Do you think David Blumenthal does not know that HIMSS is involved with shaping policy at HHS? Do you think that Blumenthal does not know that HIMSS created the EHRVA and CCHIT?

  11. BlueDog,
    I am glad you are going to post this to the Register. I have to admit that I don’t follow each person to the extent you do, and what you wrote here is of great concern to me. I did notice for a while that in all these committees and workgroups and semi official bodies, the same names keep popping up, as if there is one little pond of “experts” that get recycled into every new government effort. I guess I should have checked their pedigrees more carefully.
    I don’t know, but for some reason Dr. Blumenthal strikes me as being honest….

  12. Margalit,
    the Federal Register is precisely the area where these comments should go! All comments and opinions should be posted regarding the corruption and infiltration by the HIT industry. It is not about Patient Safety. There must be transparency in government. I have not had the HIT Kool-Aid, so I plan to post my comments soon. The govt cannot fix the problem unless the corruption and infiltration is exposed and is part of the Federal Register.
    It is important for everyone to participate, so that each voice is heard. However, I believe that because the ONC is run by David Blumenthal, and that David Brailer has stated publicly that he was influenced by his underlying at the time (Blumenthal), that many comments will be disregarded. Brailer awarded CCHIT a grant contract of $7.5 million with “minimal standards” set for certification. That was Brailer’s vision…do you think the govt will ever admit they made a mistake regarding CCHIT? ONC is now trying to distance themselves from CCHIT.
    Let’s face it, HHS committees are infiltrated by HIMSS BOD, HIMSS EHRVA, and HIMSS task force members. The Standards Committee alone has HIMSS BOD Liz Johnson (Tenet Healthcare) and HIMSS BOD C. Martin Harris, just to name a few.
    Charlene Underwood (Siemens) has been involved with the HHS Policy Committee. She was also involved with HIMSS’ first Mideast conference in May 2009 in Bahrain (coincidentally, during the time that the PBS Frontline: Black Money was aired regarding Siemen’ corruption in the Mid East).
    These HIT companies are members of the HIMSS EHRVA. And Lisa Gallagher, HIMSS Privacy and Security Officer, has presented public testimony to Blumenthal and the HHS Privacy Workgroup in November 2009. Ms. Gallagher is also a lucrative contractor for CCHIT under Javelin Technologies (the revolving door).
    People at HIMSS have not managed to take the Federal Register away from the public, but they are working on it. Make no mistake, they work 24 hours a day to get what they want. You can count on it.

  13. Thanks, Margalit; I took your advice about commenting. Interesting; they want to know what organization one is from. Wonder how many truthful answers they’ll get.

  14. BlueDog,
    By Government, I mean ONC. The current ONC, as run by Dr. Blumenthal and the various committees.
    I will be posting my own comments to the Federal Register, but I think I’ll just stick to the point of certification. I don’t believe political comments were requested, and I don’t believe that the Federal Register is the right place to post those.
    It is of course your prerogative to believe that the entire system is so corrupted that there is no point in engaging in conversation.
    I am not at that point just yet, so I think trying is better than doing nothing.

  15. Margalit, can you please clarify by what you mean by “the government” in your statement below?
    “The Government has asked for input on their proposed EHR certification model. Why not submit your comments, so the Government gets an idea of the prevailing concerns out there?”
    Do you mean by those in government who are able to shape policy? Do you mean by Healthcare Czar Nancy DeParle, with lucrative ties to Cerner? Do you mean by HHS National Coordinator David Blumenthal, who received grants from GE (GE is Mark Leavitt’s former boss)? Do you mean by the HIMSS’ EHRVA and HIMSS’ BOD involvement with HHS Policy Committees and HHS Standards Committees?
    HIMSS, HIMSS EHRVA, and HIMSS CCHIT have infiltrated the government, beginning with Tommy Thompson and David Brailer. It is admirable to post your comments so they are part of the Federal Register. But until the government removes the HIT vendors from government roles, and stops HIMSS’ infiltration of the government, our concerns will be tossed aside.
    Do you mean an Oligarchy? This is what the great President Eisenhower warned about. You can’t have government, by and for the people, when it is run by big business interests.
    BTW, the idea of the “revolving door” comes from the Eisenhower period. Their is an idea that this does not exist today, then how do you explain Glen Tulman, Nancy DeParle, Mark Leavitt, David Blumenthal, Tom Daschle, Tommy Thompson, David Brailer, etc., who are still involved with shaping policy in government? Their constant presence is felt at government meetings, with their hands out for mo’ money. This money is not meant for the testing the safety of these devices, it is meant to fatten the bottom line of the big HIT companies.
    Why don’t you post my comment to the Federal Register and sign your name to it, if you agree with it?

  16. I agree with Janowitz and MD as Hell. President Obama promised to work with Republicans to reform healthcare. The health care bill is designed to provide health care to tens of millions who lack it and ban insurance companies from denying medical coverage on the basis of pre-existing medical conditions. Most people would have to get insurance by law, including poor and middle-income Americans. Subsidies will not help those that are already financially strapped, who are one step away from losing their homes because they lost their jobs.
    President Obama wants to create a “commission” with authority to force savings in Medicare, and is seeking the deletion of items sought by individual senators. Does his vision of a commission resemble David Brailer’s vision for creating the commission, CCHIT? God help our country!!
    President Obama is obsessed with his vision of “health care reform”. I agree that the President’s tactics to circumvent parliamentary proceedings and ignore the Constitution will cause the President to be impeached.
    President Obama is employing techniques learned only in Chicago: Al Capone had a leading role in the illegal activities that lent Chicago its reputation as a “lawless city”. That reputation has only intensified with other countries referring to Chicago as “Crook County”. It does not help that former Rep. Governor George Ryan and former Dem. Governor Rod Blagojevich were both tarnished by scandal, and both arrested on Federal corruption charges. “Pay to play” schemes to obtain personal gain through the corrupt use of authority in Illinois, and especially in Chicago, are a common every day event. Ryan was convicted on Federal corruption charges and he entered a Federal prison on November 7, 2007, to begin a 6.5-year sentence. Blago was impeached and his trial date has been set for June 3, 2010.
    If President Obama is forced to step down, he can always apply for a job as a lobbyist at HIMSS.org. He will be following the footsteps of Tom Daschle and Tommy Thompson, who are now successful HIT lobbyists receiving millions of dollars in Federal grants. The Executive Order for the universal adoption of EHRs will forever be known as “Lead and Prosper”.
    President Obama has turned a blind eye to the corruption that began in his own backyard, in Crook County, IL—home to HIMSS.org and CCHIT.org. I, too, was one of millions of Americans seduced by Obama’s promises of healthcare reform. There is widespread corruption and solicitation of bribery in Illinois, so it does not surprise me that HIMSS.org and CCHIT.org have been successful in not only pursuing their agenda for universal EHR adoption, but have done so successfully with lack of FDA oversight.

  17. Here is my suggestion to all physicians commenting here or just reading and agreeing, or disagreeing.
    The Government has asked for input on their proposed EHR certification model. Why not submit your comments, so the Government gets an idea of the prevailing concerns out there?
    You cannot affect change unless you make your voice heard.
    The comments are public, thus cannot be ignored.
    Here is the URL for commenting. You have until 5/10/2010.
    http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480ab9d0e

  18. MD as HELL, you do make a point that I brought up several times and never got a clear answer. Is the documented thought process, particularly in assessment and plan, really the doctor’s intellectual property? If so, should the sharing of medical records be limited to hard data only (vitals, procedures, test results, meds and diagnosis)?

  19. The patient paid for the work but not the record of the work. I prepare it so I can interact with the patient’s insurance company and so I can defend myself from the patient. I do not need a record for anything else. The patient can make their own record. I will give them anything they paid for, like test data and labs, and my recommendations. However, my written opinion is mine. I own it, created it, stored it. Maybe I should sell a license for it like a software vendor.

  20. Doctors have wimped out, yielding to pressures to use out of the box meaningfully user unfriendly CPOE by hospitals partnering with the usual big business HIT vendors, with nary a complaint about the adverse incidents these ordering machines visit upon their patients. Meaningful use is a euphemism for meaningful control of medical care and the medical care finances.
    It has nothing to do with what is best for the patients.
    Does the readership of this blog desire to buy or participate in this scandalous takeover of medical practice that may have links to or exist as organized crime?

  21. Yes, EHR guy, your last comment reminds me of the NRA’s famous line, “guns don’t kill people; people kill people”. (NOT to start another rage-filled debate!)
    I have seen hospital information systems do bad things with my own eyes, many times. You can blame it on a bad programmer or a dumb user or whatever, but the basic fact of patient safety is that systems must be designed to minimize human error, be they IT systems or work processes. If the vendors won’t do it, somebody else must.
    And ps, just to set the record straight I have been retired for 5 years; my only active role right now is as a patient and patients’ relative. No shill here.

  22. To the Guy HER,
    EMRs are geared to the least common denominator of mediocre physicians and the paraprofessional NPs and PAs who require order set programming reminders to get a blood culture when a patient has a fever. EMRs keep mediocre physicians in compliance with guidelines. Mediocre physicians, the PAs and NPs love EMRs and would never blame an EMR for killing a patient.
    You are sooooo wrong in your over the top accusations:
    “Mediocre clinicians blame the deaths or injuries of their patients on an EMR!
    Those healthcare providers that treat their patients as assembly line products are guilty for homicide and manslaughter!”
    On the contrary, it is the thoughtfully gifted clinician who determines that the etiology of premature death is the assembly line scripted by the mistake prone and error generating EMR’s electrical orders menus, about which the vendors were aware. There is gold in that mine for criminal investigators.

  23. Now seriously.
    Has anyone seen the recent photo of this guy called HIMSS CEO Steve Leiber
    on the HIMSS Executive Bios web site?
    I remember him from years ago, before he drank the Kool-aid. I can tell you by looking at his photo, the morphological changes speak to excessive consumption of EHR cocktails- you know the stuff that hasn’t been certified by the pharmacy.
    YIKES! Does anyone want him making decisions for themselves much less 310 million people?
    I can’t believe this guy even a has a drivers license. Mayor Daley might consider putting up Caution road signs with his picture on it.

  24. Missing Cartoon piece above, imagined words of EHRVA Gladiator , H. Steven LIEber
    “Well Hello Boys and Girls,
    Are you alive?
    Did you bring the 19 Billion Dollars?
    Bring it to me now!, Call that David Dude and get me that cash fast!
    I need to fix my craving for an EHR cocktail of God knows what they are mixing to today , but yum, yum, ooh dat cool aid sho-wah is good!
    You all have a nice Tax Day now , ya hear and don’t forget to come to my meeting next year.
    Harry”

  25. Mediocre clinicians blame the deaths or injuries of their patients on an EMR!
    Those healthcare providers that treat their patients as assembly line products are guilty for homicide and manslaughter!
    Like Praetorius indicates: “nurses pay attention to the terminals but not the patients”.
    Also, I am not saying that EMRs shouldn’t be verified and validated but I am saying that the FDA can bankrupt any company with their bureaucracy and red tape.
    I can see a few shills in this discussion.
    The EHR Guy

  26. Mr. More,
    Yes, I am a crazy coming out. Thanks to you and the posters here, I feel meaningfully safer to come out of the HIT critics closet after your report on the meaningfully uselessness of current HIT, EMR, and EOE devices.
    The HIT vendors want the skin of those experts who demand that their products be safe. They want the skin of those who report the adverse events and violate the do not disclose contracts.
    Sorry vendors, I will be reporting. It is my obligation.
    The vendors do not have patient safety as a priority. It interferes with their profits.
    I for one have seen deaths and injury of innocent defenseless patients. It seems that the nurses pay attention to the terminals but not the patients.
    I feel relief coming out of the closet and I hope more of my coworkers do the same.

  27. Here we go again. Gary, the patient sat for the portrait, but I painted it. It is my record.

  28. Dear EHR Guy,
    I don’t know which vendors will benefit from FDA oversight of EHRs, and it should not matter. It makes sense that the barrier to entry will be much higher, but maybe it should be, and for hospital EMRs it already is.
    Maybe we don’t really want any random group of three developers and a doctor to go ahead and deploy their creations in a clinical setting at will, just like we don’t want any kid with a chemistry set selling new drugs online.
    Do you think the FDA is stifling innovation in the medical devices industry? I don’t know, I’m sure it slows things down quite a bit, but there seem to be a lot of those gizmos coming to market on a regular basis.
    Any way you look it, and maybe it’s not the FDA, but somebody needs to test for safety, and to do that you need a completely different process than certification, as I am sure you very well know.

  29. Mr. (?Dr.) Worley;
    Perhaps I am naive, but I may actually represent the future. My background is in the hospital laboratory, which is heavily computerized and also regulated, inspected, and validated out the wazoo. I just find it interesting that a computer which deals with crossmatches, blood types, etc. is recognized as a medical device and regulated as such by the FDA (which also independently inspects the operations of our blood transfusion services, BTW, along with about 3 other agencies) – but the radiologists can kill people with their software or the CPOE can kill someone with a glitch, and no one makes the connection that these are also medical devices. I truly believe this is ignorance, not willfulness – no one has ever made this connection. It will come. And unfortunately, EHR guy, patient safety supercedes your company’s survival. There ARE companies who make standalone blood bank software and survive, so it must not be THAT onerous.
    In my opinion the major problem with today’s predominant health IT product is that it is monolithic and tries to accomplish too much with one product. We went from large HIS’s with modules for cardiology, radiology, etc. to “best of breed” stand-alone systems which were interfaced with each other, and now back to the larger monolithic systems. I think this is all due to lack of knowledge of how to apply IT to healthcare – seriously. As today’s younger generation grows up with this stuff and becomes doctors, nurses, and even software vendors, I think there will be a more intuitive understanding of what type of systems are needed – but they are NOT today’s systems, that is for sure. For that reason I share your cynicism about “meaningful use” – there is little meaningful available to use efficiently, yet. There will be.

  30. Electronic Medical Records are useful tools,but what I have observed is that the learning curve is excessive and errors are numerious.Not to Mention,the crash time that continues to plague new systems.
    Patients have every right to view their own electronic records to ensure their accuracy and the reduction of medical Errors.
    The Profession has been able to exclude patients from viewing records under the guise of the HIPPA Laws. The same laws that impede, on patients rights, provides cover for the profession and shares it with everyone but your employer.Any one that views your record in what ever compacity needs to be reported to the patient of such access and the purpose thereof.After all who’s records are they? Certainly ,not about the provider!

  31. Dear Bev MD who asked, rather naively: “I don’t understand why entire hospital information systems are not. They should be; they do affect lives too.”
    You do not have to wonder any longer. Merely read the report of Dr. Schwartz and revelations about this guy LIEber and voila, the answer to your question. Throw in a couple of pennies for good measure.
    Dear The HER Guy who states: “If you have ever worked under the scrutiny of a quality process required for FDA conformance you must know how painful and costly it can be.”
    This can not be any more painful and costly than patients suffering horrific deaths in the experiment being put upon the unsuspecting public. Besides, your expertise will become worth $$$.
    Only 6 deaths have been reported to the FDA. Come on people, start sending them in. I know they are out there.
    Stand up to your hospital champions who support HIT disruption. Turn the hospital CEOs in for subjecting patients to undue risks and covering up the adverse events.

  32. Dear Dr. Schwartz,
    I believe the big vendors would benefit with the FDA regulation of EMRs.
    I think your points are a perfect example of sophistry, in a good sense I mean, and albeit you state many facts your conclusion is erroneous at the very least.
    But good try on the HIMSS, CCHIT, EHRVA, Big Nasty Vendor (BNV) “conspiracy theory”.
    By the way, why do you always capitalize the first 3 letters of Mr. Lieber’s name?
    The EHR Guy (Tells the truth with a bit of sarcasm)

  33. I think everyone needs to step back and look at how all of this began. In 2003, HIMSS CEO H. Stephen LIEber, along with more than 70 major IT companies and health systems and 80 senior executives, signed a declaration: “Bridging the Chasm: Realizing a Universal EHR – HIMSS pledges to convene the public and private sectors in
    an effort to achieve improved PATIENT SAFETY through EHRs.”
    Lieber acknowledges pushing for the permanent full-time position of National Coordinator for David Brailer, who was David Blumenthal’s predecessor. In 2004, Lieber opened an office in the Beltway solely for the purpose of lobbying full time for nationwide EHR adoption.
    David Brailer, MD had a vision for a certification commission. Low and behold Lieber created the EHRVA (electronic health records vendor association) and the popup “501c3” CCHIT. Mark Leavitt admitted in his Matthew Holt interview that he was “assigned” to the role of CCHIT Chair only 10 months after working for HIMSS. How was Lieber able to bypass government approval for the position of CCHIT Chair? Lieber planned to transition an “EHR vendor” with no healthcare organization experience to the role of CCHIT Chair, but first had to legitimize Leavitt’s experience with a healthcare organization by bestowing the title of CMO of a “healthcare organization” unto Mark Leavitt.
    David Brailer should explain why his vision of a certification commision for EHRs did NOT include testing of products for safety. Why did Brailer allow the creation of CCHIT to “certify” products when the FDA has had the responsibility for testing medical devices in a real lab. Once a product comes in contact, whether directly or indirectly, with a patient, it IS a medical device.
    The FDA has a real laboratory and not a virtual lab with a “pass-fail” system, in which no records are kept of the certification process. What proof does CCHIT have to show the taxpayer that it did not squander millions of dollars that should have been given to the FDA? HHS has oversight of the FDA, so it does not make sense that CCHIT would be allowed to “certify” products that have not been tested for safety. The FDA should be removed from HHS’ authority. It is a conflict of interest to be in charge of both “certification” and the FDA.
    We all know HIMSS was successful in lobbying for Brailer’s full-time, permanent position, and in turn, Brailer gave HIMSS a $8.9 million, 3.5 year contract to rubber stamp products.
    Dr. Blumenthal is the Dr. Kellog of of this decade: implementation is experimental at best, the biggest clinical trial in history, without the consent of the American taxpayer. The sole purpose for creating CCHIT was to bypass FDA testing and regulation. HIMSS has advocated this position openly since 1997, and LIEber was hired in 2000 to push through the vendor’s agenda, though LIEber lacks technical and clinical experience. Why is LIEber the voice for 310 million Americans?
    Dr. Blumenthal is inept, and should step down from his position as National Coordinator. The two “certification” bodies he is trying to establish: one temporary and one permanent, is proof that he has no clue as to what he is doing. It is too late for Dr. B to distance himself from CCHIT. Dr. B should have done a tour of CCHIT’s laboratory early on and demanded to be shown where testing records are kept. They are not at 200 S. Wacker drive!
    How does LLEber claim to “improve PATIENT SAFETY through EHRs” when doctors and nurses cannot report defects in these products? Lieber has known all along about the gag clauses in HIMSS’ EHRVA contracts.
    The Null Hypothesis definition stands: products are UNSAFE until they are tested and proven safe. Get the HIMSS EHRVA out of HHS policy and standards committees and out of government, and let the FDA do what it does best.
    It is not about “how big is your slice of the pie”. It is all about the Patient.

  34. Dear Margalit,
    You brought up the regulation of EMR software. I suppose you are referring to FDA oversight, correct?
    If this is so occurs I can assure everyone that it poses a high risk to the existence of small and medium size software development companies. It will also knock out of the game open source developers.
    For example, a specialized software industry, Computer Aided Detection or CAD, has been enduring a battle for survival for the past few years. The FDA has not granted any approvals, PMA or 510(k), to products developed by this industry.
    Of course, these companies at one point in history promoted their software as medical devices in order to raise the bar so that competition would face a huge challenge. Seems like they raised the bar to high for themselves as well.
    If you have ever worked under the scrutiny of a quality process required for FDA conformance you must know how painful and costly it can be.
    It’s not uncommon for companies to spend 10s of millions of dollars to get a product out in the market after going through rigorous design processes, quality control, and verification and validation.
    Clinical studies and trials are difficult and costly as well.
    The only ones to benefit from the FDA regulation of EMRs are the mogul monolithic vendors because they have the infrastructure and muscle to deal with it.
    EMRs will go through greater scrutiny than CAD because CAD only detects but some EMRs have entered the space of diagnosis. Diagnosis would actually give an EMR the status of medical device and most likely of Class I type.
    So good luck to all EMR software entrepreneurs! You’ll need it as you will need an EHR guy with FDA experience 🙂
    I initiated a discussion of this at the EHRNet at http://EHRNet.ning.com
    The EHR Guy

  35. This post and it’s subsequent thread reveal a truth I have seen since the beginning of my interest in RHIOs and HIE way back in 2003. IT is seductive, everyone thins IT can do things doctors and hospitals cannot. I’ve used several EMR systems and none of them save time. First of all it turns me into a secretary and I have to assume other peoples’ duties. The IT application may improve efficiency by allowing bureaucracy to rule, and also by shifting more of the work load to the physician. One has to delegate many of the systems functionality to nurses and others such as e-prescribing with the physician reviewing and signing off on orders.

  36. Wow, the crazies are really coming out of the closet now! Get hold of yourselves, people!
    MD as Hell: Meditech is run by several hospitals in my area who like it. As with most hospital EMR’s, user buy-in and training make a big difference as well as the product itself. If you are so concerned, perhaps you should contact their user group and find out why other people can use it and you can’t.
    Margalit: I am not as politically liberal as you, but you are a knowledgeable voice of reason on the HIT subject; thanks. I noted your earlier comments about the expense of providing a hand-holder and why certain docs’ offices can make this work; I believe this is partly a generational thing, which will fade as the younger, tech-savvy generation comes to practice and imposes their own knowledge on the vendors.
    I completely agree with your #5 above; in fact blood bank software is already regulated by the FDA and I don’t understand why entire hospital information systems are not. They should be; they do affect lives too.

  37. From the unborn to the Congress and the President in 2010:
    Get your paws off our money. You do not represent us. We would never vote for you in a trillion years. Your arrogant disregard for America and its future and our present are brazen.
    As for your pitiful “technology”, it is nothing more than an instrument of control and taxation. In our time, the future to you, we keep track of our own information. There is no need for anyone else to have it. We pay our own bills, too.
    Ever since we got rid of welfare, the people that used to be poor are now providing for themselves and their families just like it was done for thousands of years before you and the other socialists thought you could do it for them.
    You couldn’t you didn’t, and you shouldn’t try. No one needs a master.
    Thanks for showing the world how not to be American.
    Signed
    Your worst nightmare, your future providers, if we so choose when we get there.

  38. Barack Hussein Obama, is obsessed with this health care. Why?
    64-73% of Americans are satisfied with their health care so why is this need by him to make changes that the American Voters do not want. This will go down in history as the destruction of America, and the American Way. This President is a megalomaniac
    and will destroy the Constitution of the United States of America.
    This health care change will cut all of the Medicare coverage in order to pay for these changes, and diminish the seniors ability to live a healthy life. He does not care whether the Democratic party is destroyed in the process, which should have every Democratic Senator and Representative shaking in their boots, as the American voters will kick out of office every Democrat, Good or Bad. The pendulum swings just as far one way , as it does the other, and the whole barrel will be thrown out.
    I had thought Jimmy Carter was the worse President we ever had, he now seems like an Angel compared to this President. We know that Congress has had the lowest approval rating in history, and has had that during the last 4 years of President Bush, in case no one remembers that.
    You can not trust the Democratic Party as they have proven, even those that claim that they are anti-abortion, as they are being coerced into voting for a bill that sanctions use of our money to fund Abortions, as this President pushes for Abortions all over the world. To circumvent parliamentary proceedings and ignore the constitution of our country, is cause for this president to be impeached, and that goes for Pewlousy, and Harry Reediculous. Can you imagine waiting for 4 years after you have paid for something, to finally get it? And then find out that what you paid for is only 75% of what you had bought?
    For them to state that there are MILLIONS of Americans without health care coverage, does not mean that they will not get health treatment. Any of them can walk into the hospitals(just as the illegals do), and be treated and cared for the same as anyone else. That is a political smoke screen, and does not ring true, that those people are without medical care. It is not too difficult to prove, just walk into the emergency room at the hospitals, and they will tell you that they can not turn away anyone that seeks medical treatments. If the President and Congress keep spending with the Health care fiasco, and the Cap and Trade bills, in 5 years our country will go into default the same as Portugal, Italy, Greece, and Spain are heading, to be followed by Great Britain, and then the United States of America.
    You hard working people had better get on the telephone and computers, and let your voices be heard. We did not fight for freedom in 1776 for nothing, and to have taxes and spending pushed upon us , without representation , that truly represents what the American people feel. If this bill is pushed through, and rammed down our throats, without an outcry, and voting those who have done this out of office, then
    we deserve what we get. Just think about how you will explain this to your Grand-children, as I don’t think with the new health care you have to think about
    great-grandchildren, as the health care committee that you will have to meet with every 6 months will not allow you to live that long.
    This is my honest opinion. God Save us All

  39. John,
    Every story has two sides, and this one has more than two.
    (1) It is incorrect to lump EMR software for Hospitals and ambulatory clinics together. The size and scope of usage are vastly different. The choices and quality are also vastly different.
    (2) There is no denying that there is an abundance of bad software under the umbrella of EMR. There is also some software that is equitable.
    (3) EMR vendors cannot provide guarantees against loss of productivity, mainly because it would take hundreds of contract pages to legally define productivity in a clinical setting.
    (4) EMR vendors should be liable for damages ensuing from direct use of their product if proven so in a court of law.
    (5) EMR software should be subject to regulation. Not certification that the nuts and bolts are there, but assurances that the nuts and bolts are providing the benefits claimed to be provided, and the risks of usage are within acceptable limits and clearly labeled. We have regulatory bodies that provide such oversight in other markets.
    (6) Sooner or later medical records will have to be computerized. I suggest that we concentrate on how to do that best, instead of advocating paper. Whatever efficiencies paper has today, and there are many, can, and will, be vastly improved with appropriate technology. It’s not a question of if, it’s a question of how.

  40. Chilly John,
    No one gives a hoot about the comments. The government and HIT industry shills are forcing an experiment on its citizens. You said “Adopting IT, effectively, takes time and commitment before true productivity gains (ROI) are realized.” It would appear that you are advocating to sacrifice patients now (let them die as guinea pigs) to enable you and your HIT ilk to lead and prosper.
    And for Kibbe who states: “But then they pull out their iPhone and demonstrate time-saving apps they use every day from that platform (or similar devices.”
    That is a vapid statement which is not relevant to the fact that the current iterations of HIT (esp CPOE and e-RX) products are MEANINGFULLY UNSAFE and CLINICALLY USELESS. You, Dr. Kibbe, of all people, should be demanding that the hospitals report HIT caused deaths in these government sponsored experiments, and not be used by the HIT industry.

  41. Impressive comments and perspectives regarding EHR adoption challenges. Thank you all.
    A few reflections:
    I worked in the mfg sector, large IT enterprise systems, and there are many analogies and lessons that can be drawn from that industry’s experience in IT adoption and the healthcare sector’s.
    1) Adopting IT, effectively, takes time and commitment before true productivity gains (ROI) are realized. In mfg it was nearly a decade before gains were realized.
    2) Workflow is always a challenge but rarely if ever should one try to code existing workflow practices into a new enterprise software solution be it ERP or EHR. A recipe for disaster. A very delicate balance must be struck between adopting out of the box workflow and customization to existing workflow practices. Careful review of a vendor’s solution is required to best match capabilities to needs (doubt many in this industry, esp small practices, have the skills to do this assessment correctly and doubt RECs will be much better).
    3) Smaller, modular apps such as those David referenced can serve as a stepping stone to more complete solutions. My issue here is that it will require quite a few of these modular apps to create a system that will meet meaningful use requirements for incentive reimbursement. Also, the challenge with modular apps is that there are differences in UI, log-ins etc across an array of such solutions which ultimately contribute to productivity losses.
    With comments on the proposed MU rules due on Monday, the 15th, my primary goal in authoring this post was too simply bring forth the very real issue that adopting an EHR is often very challenging with productivity losses exceeding the monetary gains from the planned incentive payments. I’m not exactly sure how to address this challenge, but as I said in the close of that post, maybe it is the vendor’s that need to step up to the plate and truly demonstrate (guarantee) their solution will not lead to huge productivity losses.

  42. We turned on our new Meditech 6.0 system a year ago. It remains a total disaster. Our ED length of stay has just about doubled. Time to admission and time to discharge increased by nearly double as well. Nursing documentation is useless, since it is not what the doc needs to know. Maybe it will pay off in the court room defending bad care with a mountain of data. Calling it a boat anchor is an insult to anchors.
    Give my nurses pen, paper, and telephone.
    It is great to have electronic records stored. It sucks to try to deliver care and compute in real time. It cannot be done. Anyone who thinks it can be done never had to move volumes of patients very rapidly.
    So we will build a new, bigger ED and put our same sorry useless systems in it. How stupid is that?!

  43. Fascinating discussion. Each of you who commented and the primary author have that wanton nuance. You have all been seduced by HIT dreams. Something is missing from HIT. Once the hype has subsided and you wake up, you still have to solve complex medical problems, but now, you have an expensive electronic impediment that can not be trusted.
    Many of the problems you report would be solved if the HIT makers would not have covered up their products’ defects and would not have extended a charade of safety to Congress in the form of CCHIT.
    At long last, meaningful safety may be forced upon the vendors:
    http://www.huffingtonpost.com/2010/03/11/fda-asks-hospitals-to-rep_n_495691.html
    Read the letter sent by the FDA, at the report’s end.

  44. Here is the rub, bev. If vendors would engage in the sort of support that seems to be required for the current state of the software, the prices would have to go up significantly. The truth is that profit margins for EMR vendors in the ambulatory market are already small, particularly for the SaaS model, and the market will not bear any increases.
    The truth is that most implementations are neither complete failures, nor resounding successes. Those that do well are less publicized, and there are probably less of them than the nightmarish ones.
    The EHR Guy’s list is perfect, but the questions that James is asking need to be addressed.
    Physician are being bombarded with promises of “easy to use”, ready to go-live in 5 minutes, no out of pocket costs, just sign up and use it the first day, and all sorts of nonsense. As a result many doctors come to expect that implementing an EMR is like buying a new car. Sign the check and drive away. It is not. It’s more like getting new orthodontic braces.
    I think what sets apart the successful implementations is the fact that these clinics were looking for an EMR to solve problems they identified in the practice. Be it low reimbursements, large fax volumes, lost charts or anything else, they had a well defined business goal and they sifted through the vendors until they found the one that best addressed their issues. I am not sure why, but these very well prepared physicians, seem to understand that implementing an EMR is a process, not a task and they are in for the long haul.
    They demand training and on site support and often are willing to pay the extra dollars.
    At the other end of the spectrum are the physicians that just want an EMR because everybody is getting one, and “would you be so kind to have it installed while I’m on vacation next week?” (real story). These folks will fail miserably and suffer all the way through.
    Now, I’m sure the software will continue improving and become more intuitive and more reliable and all the good stuff that comes after the tipping point, but I can guarantee that any software that has to model the practice of medicine will always be complex enough to have a significant learning curve.
    We have been comparing doctors to pilots lately with regards to checklists. Practicing medicine is probably more complex than flying a plane, and the software to assist in medicine is probably more complex than the software assisting the pilot. In both cases, it takes time to become proficient, and the expectations should be set accordingly.

  45. I think the EHR guy has hit the nail squarely on the head.
    I viewed this situation from the other side, as a hospital-based physician implementing multiple laboratory IS’s. (Although it’s not a dr’s office, it is smaller than a hospital-wide implementation so is somewhat analogous). All of his points are extremely well taken and I experienced almost all of them. I think the vendors need to provide someone, preferably with clinical experience, who will be the cheerleader/trainer/troubleshooter before, during, and for an extended time after the installation, to minimize and solve these productivity and other problems. (e.g. massively beef up his point #6) It would be well worth the huge hits to their reputation, complaints, customer calls, etc. etc. that they are suffering now after yet another failed installation. I just don’t get it – if they think they are saving $$ by not providing such a person, I think they are dead wrong. To say nothing of better designing their systems as EHR guy describes. Their markets would skyrocket if they would just UNDERSTAND their customers’ point of view!

  46. This appears to be an issue where the outcome depends upon the right system being supplied from the right vendor to the right practice at the right price — and then implemented the right way. So, why do some practices have great experiences with the EHR conversion and others have such a horrible time? What do the ones that have a good outcome do differently? What are the best resources available to help increase the odds of a good outcome?
    If the TCB readers were assembling a list of “do and don’t do” in this regards, what would be on it? If you were asked to advice a medical colleague, what resources would you point them to as especially trustworthy and helpful?
    On a related note, what are the resources that are available now that are inexplicably overlooked? For example, there are EHR satisfaction ratings promulgated by type of practice and size by physician sources and others. There are clear winners and losers when it comes to how well certain systems and vendors mesh with certain offices. Why do potential buyers not use them? Why are vendors with uniformly low scores in certain categories continuing to make sales in that market segment?
    The RECs are supposed to be a help in this regard at some point, but until then, what is the best advice that the TCB has on the topic?
    Also, while the focus is typically on physicians, I wonder if smaller and more rural hospitals might face an even bigger challenge.

  47. That is a very good list EHR guy. The problems you describe are common to far too many software packages across many industries. Human factors and making the software work into existing ways of working are usually the weakest point because that requires initial observation and incremental interaction with the users to find out how they would best interact with the system.

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  57. Doctors and hospitals are not being as diligent as they should when choosing an electronic medical record.
    They are basing many of the decisions on the cost of “software” when software might just be the “least” of their worries.
    There are many small “resellers” of software right now who are at a stage where they can be negotiated with for onsite training and implementation.
    I know of one EMR company that offers: 3 days of training and then after that, the physician pays over $700 per day for training, plus airfare and lodging.
    At the complete other end of the spectrum, I know of an electronic medical records company that is providing one year of free training.
    Again, phsyicians need to be more diligent in the selection process.

  58. “Many physicians with whom I speak are angry that anyone, including the government, could be so tone deaf as to suggest they should adopt technology that creates even greater economic stress.”
    Yes, we’re angry, and many of us are most angry at our own professional organizations that continue to lie to us about the reality of EHRs. The behaviour of the AAFP has been particularly egregious in this regard (Dr. Kibbe excepted), having chosen to transform itself into an unquestioning publicity arm of the EHR industry rather than represent the interests of practicing physicians.
    Thanks you, Mr. Moore.

  59. EHR Guy,
    ePrescribing is successful because it actually has tangible ROI in the form of reduced phone calls and reduced time to deal with refills. And the cost of ownership is low, since pharmacies basically pay for it. You may be skeptical, but it is also successful because of the original 2% incentive offered by Medicare.
    Low entry cost + tangible ROI + incentive = success
    This is the only formula that will work for small to medium size practices.
    As to mistakes in the implementation process, of course those can derail everything, but that has nothing to do with the quality, or lack thereof, of the software.
    Dr. Schwieterman,
    Saying that “Registries, e-prescribing, and web portals are good examples of proven technology that meet these criteria.”, makes it sound simple, but it is not. If you stop to think about it, efficiently implementing all three, pretty much requires that you implement the entire MU, unless you are willing to do an enormous amount of typing.
    I completely agree with Dr. Waldren’s analysis. If you look at industries that used IT to computerize the business and realize efficiency, they all automated very well defined manual processes. There are very few of those in health care, and the ones that are standardized enough, like prescribing meds, or billing, have been computerized successfully.

  60. IMHO, there are 3 fundamental root causes of our current state of affairs as it relates to health IT. (1) What we pay for and what we value are different and (2) there is no ability for health IT system substitution in the market and (3) a high level of unnecessary clinical variability
    Pay for and Value
    We pay physicians to see as many patients as they can and do as many procedures as they can. We value high quality, cost effective care. From a process and technology standpoint, they are inconsistent. The processes and technologies that lead to improved quality and cost, take more time. Those that make practices fast, lack the ability to markedly improve quality or lower cost. A physician or practice that delivers high quality care cannot differentiate themselves financially.
    No substitution in the market
    Once a practice purchases health IT their is a large cost to switch to a different system. Data does not move, it is financially costly, and it is resource intensive to learn/adapt to a new system. Therefore, from a business perspective, as a vendor why would one spend more money on usability and workflow instead of spending that money on marketing and sales? Once systems can be reasonably substituted, the incentives for vendors align to making products that are highly usable and deliver outcomes.
    Unnecessary Variability
    We lump the practice of medicine all together, instead of understanding that the practice of medicine is actually delivering multiple product lines. Some of these product lines (i.e. treating a UTI or managing a diabetic) are what Clayton Christensen calls “value added process businesses.” These VAPBs can be highly standardized as there is evidence on how to treat and manage these problems. With this clinical standardization, we can standardize the UI and workflow within health IT systems. The other type of product line is “solution shops”. This type is harder to standardize and requires highly skilled experts, an example of such a product would be the diagnosis of an undifferentiated problem. If we do not separate these to different types of products, we will continue to not standardize the clinical process and the health IT to support it.

  61. David,
    I would just like to commend and echo the comments from David Kibbe and Jeff Goldsmith. According to the top doc at Sermo, 80% of docs feel EHR is good idea but few feel they can afford the upfront/ongoing costs and productivity disruption they inevitably induce.
    Like David, I feel that the industry would be better served by first implementing the technology that has the capacity to improve care, lower costs, and at least maintain the status quo productivity. Registries, e-prescribing, and web portals are good examples of proven technology that meet these criteria.
    The realities of operating a modern practice are such that this is the only way a for-profit business (don’t laugh at that docs) will en masse willingly embrace the formative change to ‘connected health’- a concept few can argue in not in the best interest of our healthcare system.

  62. Jeff: I’m not sure how or why you’re interpreting what I’m saying the way you have done. I’m certainly not making excuses for the EHR products. I agree entirely with your statements about the lack of adoption being a result of lack of benefit bestowed on the business/enterprise. That’s exactly the point.
    DCK

  63. Excellent post!
    Hindering productivity has always been the case with EHRs, EMRs and almost every single software application aimed for the clinician while doing their clinical tasks.
    Most of the problem can be traced to contextual usability.
    For example, ePrescribing is one of the most successful clinical software applications because the doctor enters into a clerical mode while prescribing. It’s convenient to sit at a desk, select the medications on a conventional computer, review and press [Send]. This is one example of contextual usability that does not hinder productivity and disrupt the clinician’s natural workflow.
    Another example of contextual usability would be that of the radiologist at a PACS review workstation. This is a natural setting for the radiologist. He sits in front of a few display monitors and goes through the studies in his worklist, makes some annotations, dictates some reports, etc. But beware if you add an extra image to his/her accustomed workflow! Their contextual usability breaks down and they will protest, loudly.
    Technology is supposed to help but most vendors don’t get why and where they’re the problem.
    Until we design software and/or devices that take into account the different contexts a clinician finds himself/herself during their daily workflow we will have little success in getting them to implement technology.
    Other factors that bring down productivity while implementing an EHR or EMR are:
    1. Low clinician buy-in,
    2. No clarity or a roadmap that others can follow, the implementors don’t understand the needs of the clinicians and the clinicians have no idea what is going to happen next,
    3. Lack of training before implementing,
    4. Poor workflow analysis, cookie-cutter approach is detrimental to the practice/clinic,
    5. Lack of a champion withing the practice/clinic,
    6. Poor support, most vendors have very few support people to follow-up on the implementation,
    7. Complexity of software, most try to do so much that they end up doing very little,
    These are just a few of the ones I have encountered in a career lifetime of implementing software in hospitals, clinics and practices.
    The EHR Guy

  64. It’s like renovating your home, David.
    There is very little risk in redoing the kitchen one year, adding a sun room the next and maybe finishing the basement when the kids are older.
    Tearing down everything from the foundation upwards and putting up a second floor, on the other hand, is a real hardship and fraught with major inconvenience, risk and expense.
    Of course, when all is said and done, you can’t turn a humble ranch house into a stupendous Swiss Chalet by incremental tinkering. However, if you have a good long term plan, lots of patience and are willing to postpone instant gratification, you could incrementally build a really nice suburban villa, on a fix-as-you-go and pay-as-you-go plan.
    So the question to ask is twofold. Do we really need (want) a Swiss Chalet, and can we afford it?
    The other question to ask (since I just saw Jeff’s comment), is if a Swiss Chalet will work well for us in the hot and humid Florida beach community. And for that matter, is a sun room a good idea in this hurricane plagued neighborhood?
    Maybe we should revise our building plans and stick with a nicer kitchen and some reinforcements to the foundation and wait and see if that hurricane proof construction glass can be perfected and when it comes on the market at a reasonable price, we should go for it.
    Alas, the neighbors are going to have to wait a little before our humble abode makes its contribution to raising real estates prices in the subdivision, because this is our home and first and foremost we need to consider our comfort and our ability to pay for all these, very nice to have, expansions.

  65. But, David, if the existing “comprehensive” products remain difficult to use and do not create meaningful productivity offsets, doesn’t that beg a large question about the products themselves, not about how or how much we pay small practitioners, etc.?
    Name another industry that is being asked to implement IT because it’s good for the society but not for their enterprises. Name another industry with so little concrete evidence of operational savings from IT implementation, or so little validated enterprise level ROI from the investment. This isn’t a question of aversion to technology. It’s that we’re not getting iPhone functionality from enterprise level HCIT, large or small. Not even close.
    And all the stories about awesome programmatic innovation based on clinical IT seem to be from organizations well into the second DECADE of adoption. Geisinger, for example, made their enterprise IT commitment in 1995. The Mass General has been building their system for over two decades.
    This posting, which echoes what I’m hearing all over the country, is a comment on the tools, and clinician users’ codependence. It sounds a bit like you’re making excuses for products that aren’t getting the job done.

  66. Interesting post, John, and not an uncommon story, I’m afraid. Have you ever heard of a small practice or clinic experiencing the implementation of an e-Prescribing software app as a “complete disaster” for the practice? Or implementation of a patient web portal? Or a disease registry? Or a chart notation app? Probably not. Low switching costs for these components keeps the risk lower than for a comprehensive EHR from one of the “popular” vendors. Many of these are very low cost, some of them free, and rarely do they impact productivity to the point of being a “complete disaster” for the economics of the practice. The fact is that many kinds of medical practices are seeing their reimbursements decline, due to the poor economy, unemployment, and, of course, the health plan premium increases causing more and more people to go uninsured, or become significantly underinsured. In this environment, and under fee-for-service payment, the practices must find ways to lower overhead costs and see more patients per unit of time. Many physicians with whom I speak are angry that anyone, including the government, could be so tone deaf as to suggest they should adopt technology that creates even greater economic stress. But then they pull out their iPhone and demonstrate time-saving apps they use every day from that platform (or similar devices.)
    Kind regards, DCK

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