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EHR Mythology 101

Healthcare IT is bustling with activity these days. There are big changes in the air and, only time will tell, but we may be witnessing a defining moment in HIT. Naturally, everybody involved has an opinion and some folks, yours truly included, have more than one.

Below are some of the more popular opinions amongst physicians and a considerable portion of industry analysts.

The current EHRs on the market are outdated legacy systems

This is the battle cry of every new entrant to the market. First the ASP, or web based, vendors referred to the existing client/server vendors as legacy systems. This is about to change once the iPhone EHR vendors start calling the web EHRs legacy systems. One common thing that new vendors tend to gloss over is the fact that the existing vendors did not stop writing software in 1995. Most incumbents are releasing updates and major new versions on a regular basis, and by now most Visual Basic code has been replaced by .NET and the latest Java technologies. True, here and there, you can still find MUMPS platforms, but even the VA’s VistA is in the process of getting a major upgrade towards generic web based capabilities, not to mention the futuristic bombshell veteran EHR vendor e-MDs is about to toss into the mix.

One small reminder to the swooning fans of upcoming iPod/iPhone/iPad EHRs would be that these inevitable iEHRs are nothing more than a return to a closed platform proprietary (OS and hardware) client/server paradigm, when compared to platform agnostic applications like athena Clinicals, Practice Fusion, Ingenix Care Tracker or many other pure browser based offerings which can be accessed across the globe without having to purchase a specific brand of computer and without having to download a bunch of proprietary software first and without having to obtain permission to develop the product to start with.

EHR prices are small fortunes

You can buy, or subscribe to, the top of the market, eClinicalWorks EHR for $250 per physician per month. You can subscribe to Practice Fusion’s EHR for FREE. You can get Amazing Charts for less than $150 per physician per month, including the Practice Management system with the most expensive interface costing $500, and most are free. I spend more than that on Starbucks. True, if you need new computers, you will need to spend more money, but I have not heard of any futuristic EHR slated to run without hardware. Also true, there are some very expensive EHRs out there. The Bugatti Veyron sells for $1,700,000. Does that mean that cars are unaffordable? Do you even want a Bugatti? I don’t know, but I couldn’t fit my kids and dog into one of those, so I’d rather drive a Jeep.

EHR implementations fail because the software is unusable

True, implementations do fail and by fail I mean everything from throwing the vendor out to using only a small portion of the product. The question is why do they fail? Before answering that, let’s note that most implementations do not fail. Implementation failure is not limited to certain EHRs or certain specialties or certain practice sizes or certain demographic groups. It has been linked however to lack of change management, poor choice of product, wrong expectations, insufficient training, lack of commitment and all sorts of peripheral lack of preparedness. If EHRs should be as easy as driving a car, then everybody should have to take Drivers Ed. or log 200 hours of supervised driving before taking the Bugatti to the Autobahn or even to LA during rush hour.

CCHIT certification doesn’t mean anything

True, CCHIT is not an ONC approved certification body at this time, but it will most definitely be as soon as ONC approves any certification authority. 2008 CCHIT certified EHRs are very close to being able to qualify for HITECH incentives and 2011 CCHIT ARRA certified software is perfectly adequate. Considering the ONC certification plans, it is expected that multiple certifying authorities will come into existence, which is not the same as saying that CCHIT will become irrelevant. It will just have some well-deserved company. Also true, there are several smaller EHRs that have no CCHIT certification and are fully capable of qualifying for the upcoming ONC certification and they may very well apply for certification.

EHRs should be like Facebook

Social media is the hottest kid on the block. Everybody tweets, blogs and writes on other people’s walls. We have laptops, netbooks and smart phones and we are always connected to each other. I know someone who tweets in the shower. The logical conclusion must be that consumers should be able to access their EHR from the bathtub and post updates to the provider’s wall, or maybe the other way around. True, both patients and physicians should be able to access medical records from any location, but most EHR work is, and always will be, performed in a clinical setting. EHRs are tools for providing health care. For care providers EHRs are tools of the trade, not much different than CAD tools are for engineers and Visual Studio is for developers and QuickBooks is for accountants. For patients, EHRs are tools to manage health status or chronic disease, maybe a bit similar to paying bills and preparing taxes online. Nobody needs to access TurboTax in the shower.

EHRs should be about Clinical care not Billing

True, most EHRs contain coding advice and even automated E&M calculators. Most template-based EHRs go to great lengths to facilitate documentation as required by CMS to justify a particular level of reimbursement. However, as any EHR user will attest, EHRs do not force users to create convoluted, billing-justifying documentation. So why do physicians keep creating such documentation while complaining of how terrible the notes look? Probably it is because, at the end of the day, every doctor wants to get reimbursed adequately for his/her work. EHRs did not invent our reimbursement system. CMS did. EHRs are tools designed to reflect reality not utopia.

Big monolithic EHR products are bad

Modular vs. monolithic software development is an old controversy dating back to the large kernels vs. microkernels debate. In the EHR context, the single vendor vs. best of breed argument has been going back and forth since hospitals started installing MUMPS based systems. At least for hospitals, it seems that Epic has put the argument to rest in favor of the single vendor approach for EHR. For small practices, with practically nonexistent IT expertise, aggregating and integrating and supporting an array of software modules from different manufacturers, with no guarantees of ability to integrate them, may prove to be a very frustrating money pit.

Unless you are a computer whiz kid, you don’t usually go to a computer supply store and buy a motherboard and a case and a hard drive and video and sound cards and all sorts of paraphernalia to take home and assemble your laptop. You go to BestBuy and buy a Dell. Granted Dell, didn’t make all the laptop innards, but instead assembled them much like the whiz kid did, but you don’t care and you don’t need to worry about it, because if your Dell breaks, Dell will fix it, no matter who manufactured the capacitors on the motherboard.

As to the end product assembled from simple little modules, I think what Linus Torvalds, the colorful creator of the utmost open platform, Linux, said about microkernels applies very well to our discussion:

“The fact that each individual piece is simple and secure does not make the aggregate either simple or secure.”

Physicians should wait until the perfect EHR is ready

Let me go out on a limb and make one prediction here: Unless the Almighty creates an EHR for us, perfection will never be attained. Large hospitals and large physician groups are buying EHRs and are getting connected. If small practices have any chance at survival in our quickly transforming health care environment, they must find ways to increase efficiency and they must be able to participate in the soon to be mandated information exchange. Whether the canteen is half full or half empty depends on how dehydrated you are. Pouring the water in the sand because you are seeing a vision of lush palm trees and waterfalls on the horizon may not be the wisest decision you can make.

Margalit Gur-Arie blogs frequently at her website, On Healthcare Technology. She was COO at GenesysMD (Purkinje), an HIT company focusing on web based EHR/PMS and billing services for physicians. Prior to GenesysMD, Margalit was Director of Product Management at Essence/Purkinje and HIT Consultant for SSM Healthcare, a large non-profit hospital organization.

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EdgarThe S-Meisterbev M.D.Corpuscle Connie, MDpcp Recent comment authors
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Edgar
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great website, great posts. i will also encourage my friends to read your posts.http://www.comodesbloquearcelular.net

The S-Meister
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The S-Meister

Comment to Corpuscle Connie, MD Actually….Maude, the FDA reporting database, does indeed receive defect reports about EHR’s and makes interesting reading if you stumble around a bit. You can find it here: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfmaude/search.cfm Try a few vendors names and extend the search rangefrom 2005 to current. The most interesting one to search is actually Cerner which seems to have attracted a particularly diligent number of clinicians reporting on common themes. Other major vendors don’t appear at all of fair much better. Let me start by saying, the logic and workflows in most EHR’s are designed with input from practicing clinicians… Read more »

Margalit Gur-Arie
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Thanks, bev. It’s never too late, not even for Dr. E. 🙂
BTW, Dr. E. I share your concerns about privacy on the internet and wrote on this blog about that too.
I also share Connie’s concerns regarding safety and wrote about those many times.
I just believe that we need to move ahead with everything in parallel and we shouldn’t just throw the EHR out with the fear water. Those are very legitimate concerns which must be addressed and while not insurmountable, these things can only be addressed by engaging in a constructive way.

bev M.D.
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bev M.D.

I’m late to the party here, but just wanted to compliment you, Margalit, on yet another sensible, readable and informative post, not to mention your unending patience answering comments. You are one of the voices of reason on this blog.

Corpuscle Connie, MD
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Corpuscle Connie, MD

Margal said: “Let me go out on a limb and make one prediction here: Unless the Almighty creates an EHR for us, perfection will never be attained.” Not once did you mention the word “SAFETY”. I do not care about perfection, I care about safety. Doctors ought not buy, even the cream of the crap EHRs’, just because the government is bribing you. There is no place to report adverse events. C$HIT does not care once the cert if extended. Drummond, are you interested in the deaths caused by the devices you “certify”, what ever that means? Docgtors, do not… Read more »

ExhaustedMD
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ExhaustedMD

This is my last comment at this thread, but I hope people realize what I will quote below is applicable to some future “nationalized” EHR and why doctors should be wary and concerned with it being pushed without much hesitation or concern. This is from an article in the Sept 2 Rolling Stone about Jacob Appelbaum, associated with the Wikileaks matter re release of Afghanistan documents, but this comment is a generalized issue that hits home for me, irregardless how advocates will dismiss that EHR is not associated with the internet as it stands now, ALLEGEDLY: “The internet, once hailed… Read more »

Margalit Gur-Arie
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pcp, I would love to see evidence based arguments supporting the use of EHRs, but in order for that to be possible, we need to create evidence. The anecdotal studies and testimonial from both supporters and detractors are of very poor quality. One reason I can see to even attempt to obtain evidence is that technology in society in general has moved most of what we used to do on paper to computers. The other would be Dr. E’s continuity of care, which is just a promise right now, but a very logical one. The Internet and its computers are… Read more »

pcp
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pcp

And some of us are still asking “Why?” and expecting an evidence-based response. Sounds like you’re saying that question is irrelevant, and the only answer we’ll get is “Because I (not referring to the poster personally) said so.” Very motivating.

ExhaustedMD
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ExhaustedMD

Appreciate the response. Maybe sometimes silence is a statement, as responding validates the intrusion by the unwelcome party trying to hone in on the process in the first place. Yeah, EHR is going to be a fixture in medical care, and maybe it has some legitimate place, but, focusing on computer interventions just deadens the physician-patient relationship further.
Continuity of care. Now there is a term that once had important meaning, and now, is just a catch phrase for sales pitches!

Margalit Gur-Arie
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“Come on, Ms G-A, haven’t you been screwed at least once in your life by people who claim to know better than you what you need!?” Dr. E, that is exactly my point. I don’t know what you need. Nobody knows better than you and you should not allow anybody to dictate these things to you. This is why I keep asking you (physicians) to get involved and government “experts” to listen. But there is nothing to listen to, if you refuse to participate. This was written by me, on this blog, one and a half years ago: “The real… Read more »

ExhaustedMD
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ExhaustedMD

Always with a rebuttal, Ms G-A. Just curious, what do you have to offer for mental health services regarding EHR, having heard colleagues voice much opposition, responsibly I will add, that it is not equivalent to the needs somatic physicians allegedly demand. And yet this cookie cutter attitude drowns out legitimate concerns. This is why I speak out so loudly here, because the message at this site continuously is “We know what you need, so don’t tell us your needs!” Well, this is one commentor who will continue to reply, “No, you’re wrong”. By the way, the Secretary of Health… Read more »

Margalit Gur-Arie
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Unfortunately, or perhaps fortunately, the “sound and fury” do signify quite a bit currently. EHRs are being sold and implemented at an increasing rate. You can choose to state their inadequacy and leave it at that, or you can get in the game and try to shape the future. Whether you choose a passive role or an active one, you will be using an EHR in the next few years. It could be a system that was built to other people’s specifications, or it could be a system where you had some input in the final result. The choice is… Read more »

ExhaustedMD
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ExhaustedMD

Well said, medinnovation. And yet, stating the simple and obvious seems to be missed here, instead many of these posts following what Shakespeare so wisely said:
Full of sound and fury, signifying nothing!

medinnovation
Guest

EHRs are not yet ready for prime time. When they can talk to one another across electronic boundaries, when they are affordable without disrupting practices, and when they contain a readable narrative, they may be ready.

Evan Grossman
Guest

Thanks Margalit for an excellent overview of a number of EHR truisms that often aren’t. I would, however, suggest there are some areas where your chosen statements contain more fact than fiction: EHR prices are small fortunes – The price of an EHR is not the issue. Just as with a “free” puppy at a rescue shelter, it is cost of ownership, not price of acquisition that should be the concern. Software (and even ASP-based) EHRs have a variety of ongoing training, rules maintenance, backup, upgrade and other costs that can get very expensive quickly. A commonly accepted rule of… Read more »