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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The current EHRs on the market are outdated legacy systems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Most incumbents are releasing updates and major new versions on a regular basis, and by now most Visual Basic code has been replaced by .NET and the latest Java technologies.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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  1. 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 and in the case of all the larger vendors have many thousands of clinicians using them on a daily basis.
    As stated before there is no perfect device in use in medicine today, even might I say the physicians mind/memory. The regulation that may come one day will be complex, because unlike most other medical devices, the variable condition is the application of “user settings/configuration” in most modern software. Clinicians and their support agents in healthcare informatics cry for more and more configurability and ability to make the system reflect their workflow and decision making. That sets them far apart from the vast majority of other medical devices currently regulated by the FDA. The scale of user change and control in and EHR is huge in comparison
    Could I produce a configuration of an EHR that accurately reflected the very best current evidence available….yes! Would it be acceptable to 95% of the healthcare providers we come into contact with, without the ability to modify ….No!
    Every healthcare organization needs and wants the ability to modify the out of the box settings of their EHR to reflect their requirements and opinions about care. I suspect that is why the FDA despite looking at this for many years hesitates at entering the fray. Where is the line drawn between ‘as provided by the manufacturer’/default settings as placed into service by the organization/settings-data modified or provided by the clinician using clinicians professional judgement. Tricky huh?
    A knotty problem worthy of Alexander’s sword, and for now a challenge to all of us that want to see improvement in the delivery of care and clinical outcomes whatever side of the EHR fence we sit….
    PS. I apologize for two analogies in one sentence!

  2. 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.

  3. 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.

  4. 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 jump off the cliff because the government promises a few cents, which you will likely never see.

  5. 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 as an implacable force of liberalization and democratization, has become the ultimate tool for surveillance and repression. ‘You can never take back information once it is out there’, Appelbaum says, ‘and it takes very little information to ruin a person’s life’. The dangers of the Web may remain abstract for most Americans, but for much of the world, visiting restricted websites or saying something controversial in an email can lead to imprisonment, torture, or death.”
    You as an an unbiased and objective reader cannot see this could be applicable to the use of EHR? Why is it I do, and yet others, who are so gung ho that the computer systems are so impervious to hacking just because it is in a hospital system, look at me like I am talking in tongues? What reality are you living in if you embrace this attitude without any hesitation?
    Maybe if your health record was released to your employer, or to a spouse who doesn’t know all your secrets, or, your bank if you have a terminal illness and have loans with them, then maybe you would react differently? These above examples have happened, and history has a funny way of repeating itself.
    But, in the silicon world of these advocates for EHR for all, it comes down to the line in the first Spiderman I love so well:
    I forgot the part that this is my problem!
    Maybe you, Ms G-A, aren’t advocating so passionately for what I abhor, but, you have commentors here who probably don’t like what I write.
    Reality is a bitch, isn’t it, blind advocacy?!

  6. 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 managing to connect people in ways we couldn’t imagine a few short years ago. It should be able to do the same for health care, but for that to happen on a scale large enough to produce evidence, health care has to migrate to computers.
    I don’t think the lone EHR in a single practice has enough utility to justify the costs and it is almost impossible to convince folks to spend money and effort based on the possibility that there “may” be rewards in the future “if” enough people make the same decision. Couple that with the obvious shortcomings of the current software and you have a losing proposition. I don’t usually support government mandates, but maybe this one will at the very least allow us to collect some reliable evidence.

  7. 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.

  8. 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!

  9. “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 experts on healthcare delivery are not “on the Hill”, or in boardrooms of IT vendors and organizations. They are in Wichita, KS and Troutville, VA. They are busy seeing patients while public policy pundits and IT experts are deciding what tools doctors should use to deliver healthcare to this nation.”
    https://thehealthcareblog.com/the_health_care_blog/2009/03/for-whom-the-hitech-bill-tolls.html
    Yes, I do think that EHRs are inevitable, but I want you to shape them. And no, they don’t have anything worthwhile for mental health. Perhaps you could view this as an opportunity, instead of just another indicator of failure.

  10. 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 is now threatening insurance companies to basically shut up in trying to tell the public that insurance rates will go up more dramatically than what the politicians lied to us would not happen. What is that about? Could it be that the people who scream the loudest for change are the ones who are least affected by it?
    And you want those of us most impacted by these potential changes to have faith in this “do as we say, not as we do” attitude? 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!?

  11. 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 yours.
    Evan, I do agree with most of your assessments (and your boss). However, large hospitals are large enterprises and as such, they usually require large software (clinical and administrative). If implemented hastily, these things could go down, but other large enterprises in other industries manage somehow to deploy huge software successfully. I don’t see why hospitals should be any different.

  12. 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!

  13. 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.

  14. 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 thumb is that upfront software cost is only 10% of the total cost of ownership, yet the monthly subscription or software license cost is often significantly overweighted in the selection process. Savvy buyers examine the differential costs of keeping standard clinical rules and content updated in a system, the cost of upgrading as new versions come out, the amount of office work that the EHR can reduce / replace, etc.
    Big monolithic EHR products are bad – EHRs should work for doctors, not the other way around. While every EHR solution has some level of modularity to it, the path that a number of large hospital systems are going down with monolithic implementations confounds what most change management experts would recommend. Significant changes in the Meaningful Use guidelines over the next few years, and the ways in which the move toward Accountable Care Organizations will demand EHR platforms that can be used to provide situational awareness and guide specific actions at the point of care, will require EHRs to be more and more flexible. With fast-track implementations at many hospitals taking 12-18 months, by the time the software is rolled out it is often obsolete to the then current requirements. And, few of the organizations that are spending tens of millions of dollars on these implementations are putting adequate governance and staffing in place to provide the continual updating and training that is necessary to keep these systems current.
    Even worse is the myth that an affiliated physician in a nearby clinic can be well-served by a hosted version of the hospital’s ambulatory system. By the time the affiliated doctor gets access to the system (and they’re rarely the first ones to go live in the long multi-year rollout schedule) they are faced with complex screens, limited flexibility and a solution that is most likely meeting the needs that were known two years ago but not today. Worse, when the hospital decides to upgrade its system, the affiliated doctor is like a dinghy being towed behind an ocean liner, buffeted by large waves and with limited choices as to the course he or she can steer. So, even if not all large hospital EHRs are bad, I would categorically argue that monolithic EHR implementations are bad. The problem is that with the tens of millions of dollars being spent and the ten to fifteen year bonds being taken out to finance these enormous projects they are becoming “too big to fail” (sound familiar?) and it will be several years before the true fallout starts raining down. As my boss, Jonathan Bush, put it (with apologies to Charles Grodin in “Midnight Run”), “these things go down!” To read that post, http://bit.ly/cs3mmH .

  15. Dr. E, are you sure you actually read that “facebook” paragraph? I was actually saying that EHRs, unlike social media, are serious tools not to be taken lightly. Not sure why you feel insulted, but my sincerest apologies if somehow I said something offensive to you. This was not my intent.
    Of course there are glitches. Do you know any technology in a hospital or office that has no glitches, including mechanical devices (cuffs, syringes) and plain paper? We don’t stop using things because they have glitches. We learn how to deal with glitches and try to make them less frequent. This is actually true about cars, phones, washing machines and mostly it is true about people.
    I do believe EHRs must come under some sort of supervision and patient safety monitoring, but just like all those medications and devices that the FDA monitors, even then EHRs will still have glitches.
    The only question is whether the benefits outweigh the harmful effects.

  16. Sorry, Ms G-A, not a choir commentor here! Your facebook myth/assumption alone was received as a bit insulting for me, and I do not know many colleagues I have talked to who expect that kind of interaction with the technology.
    Yes, EHR is going to become commonplace, it will have benefits and glitches, and in the end, we as doctors can only hope more will be gained than lost.
    I just hope people like you championing for this to be the standard of care can explain the glitches WHEN they happen, and if at someone’s cost that is substantially disruptive if not harmful, you can console them!!!

  17. Thanks everybody.
    Mark, interoperability is indeed the missing piece. I would venture a guess that if interoperability were to come “out of the box”, there would be no arguments and no need for “incentives”. Unfortunately, folks need to take a leap of faith and trust that universal connectivity will follow widespread adoption of seemingly unnecessary EHR.
    If you stop to think about it, it is pretty amazing how much interoperability is already in place:
    Almost every EHR can send and receive data from almost every insurer.
    EHRs can send and receive data from a majority of pharmacies.
    EHRs can send orders and receive results from national and regional labs. They can receive imaging studies, radiology reports and a host of information from office instruments.
    Many EHRs have Patient Portals where patients can view, print and even download information, not to mention communicate with physicians.
    The only significant missing piece is point to point communication between physicians (hospitals), and that will not be accomplished without a critical mass of “points” willing and able to communicate.

  18. Great post, Margalit! Thanks for highlighting the free, fast, flexible EHR options that are now becoming broadly accepted in the health IT sector. Things are very different now compared to a year ago – especially for small practices with limited resources.
    Emily
    Practice Fusion EHR
    emily@practicefusion.com

  19. Great overview. I would have added a bit about interoperability which I believe is one way to improve the software as well as communication with patients, care group collaboration, and compliance with “meaningful use.”
    If everyone would build in standards based interoperability, we could easily communicate with patients (and their PHRs), do our billing, submit compliance with care guidelines and meaningful use, and coordinate care among providers. Until then we are all Balkanized and everything will be difficult. The reason people pick “all in one” solutions is that the “best of breed” software doesn’t communicate well and it takes a “whiz kid” to make it work.
    If the data in the software can move freely, then practices can pick the best software pieces and upgrade these easily. This will drive software improvement. Until then, the large integrated system vendors who have been slow to improve will have a valid argument for maintaining their closed systems.

  20. I’ll second the “great stuff as usual” comment, especially where it concerns that point about the “perfect EHR,” the HIT holy grail. First: perfection isn’t possible. Second, even if it were possible, it wouldn’t be without physician involvement and actual usage, ergo refusing to use less than perfect systems will not help create the “perfect” one. It’s not wrong to dream big (the whole quote about reaching for the moon and landing among the stars comes to mind), but if all you do is sit around and dream, what will come of it? My favorite quote from Edison is that “Genius is 1% inspiration and 99% perspiration.” The fact is that improvement requires work, on all sides (clinical, technical, academic, even *gasp* political).

  21. @Sanjay Gupta
    Yes. This was written a few days prior to that announcement and there are no “certified” EHRs even at this time. CCHIT is still the best bet (IMHO).

  22. FOR IMMEDIATE RELEASE
    Monday, August 30, 2010
    Contact: HHS Press Office (202) 690-6343
    Initial EHR Certification Bodies Named
    Key step in national initiative toward adoption of electronic health records
    The Certification Commission for Health Information Technology (CCHIT), Chicago, Ill. and the Drummond Group Inc. (DGI), Austin, Texas, were named today by the Office of the National Coordinator for Health Information Technology (ONC) as the first technology review bodies that have been authorized to test and certify electronic health record (EHR) systems for compliance with the standards and certification criteria that were issued by the U.S. Department of Health and Human Services earlier this year.
    For full article:
    http://www.hhs.gov/news/press/2010pres/08/20100830d.html

  23. Margalit – great stuff as usual. The bizarre E/M coding rules need to go as they are counterproductive with no benefit to anyone. Regulators need to do a better job of understanding the difference between paper and electronic records too – it seems they are stuck trying to apply rules and regs from a different epoch to the the new paradigm.

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