Walking the floor at the TEPR show this week brought home the wonders
of electronic medical records. The show had a multitude of
presentations on EMR use, but more than 35 years after the first EMRs
were developed we’re still early in the adoption cycle. Most
presentations were about fairly small-scale case studies. But despite
the exit of hundreds of firms from the EMR and practice management
market, and the slow emergence of several dominant players, there are
still plenty of new entrepreneurial companies with booths — and not
all small ones — out on the exhibit floor. Many of these companies
have new EMR technology that, while it may be more advanced, doesn’t
look that dissimilar to those on show a few years back.  What they lack
is a customer base. But as the legacy players in practice management
and small hospital IT systems have shown, in health care getting into
the market is relatively cheap and you don’t need that big a customer
base to anchor a business.

One of the major problems in physician
adoption of technology is the lack of familiarity with a few trusted
brands, and the insistence on doing everything differently than the
practice or hospital down the street. The sheer number of vendors
willing to support that demand for "doing it different", including
those based on software from physicians who claimed that "what was on
the market didn’t meet their needs", means that we’re a long way from
getting to the status of other industries where everyone is comfortable
with using a few widely known applications.  This might be a case where
we have just too much good old American ingenuity.

Having said that, I saw some interesting products and there are some interesting new developments that I’ll comment on later….

Edmund (Bill) Billings, another ex-Oceania MD & veteran now runs a consulting company called Phyxe helping docs get up and running with ePrescribing. 

The first key point is that vendors are not focusing on renewals…when he was judging the contest for TEPR only 3 of the 12 vendors had "renewals" as a word search that came up. Yet renewals are the biggest pain in the system–actually worse than refills.  New scripts are not such a big deal

He had an example of one solo pediatric doc who had 400 kids with ADD who needed a renewal/refill each month. Using DrFirst it went from 10 mins per to less than a minute to do a renewal, and cut the staff time, phone/fax coming from the pharmacy, etc. Another example was a 2 internist practice who used Oncall. They cut phone calls down (Major problem had been legibility).  He cut each activity’s time down dramatically (such as renewal authorization, writing new Rx, Renewal request, calls from pharmacy) and made his practice much more productive. This practice is very satisfied with Rx at their end but less satisfied with the pharmacy processing end of it, suggesting that the pharmacy is up to scratch. And this practice wants to build out from this to get to better messaging, getting Rx authorization up and running, etc.

Overall renewals are a big burden and one that the physician underestimates the impact on on their staff. Sometimes, the doc now does more of the renewals after ePrescribing.

Both of these are ASP based.  Ed says the prices is around  $50 a month but that Docs might pay more when they figure out how much overtime for their staff this might cut down on.

This may be the first time that I’ve seen a real business case for a doc to pay for an ePrescribing app.

I’m in the ePrescribing track with a couple of smart people telling us the ePrescribing will happen. Danny Sands of Zixcorp (and of Harvard) thinks that in the last year it’s really picking up in Mass with 3,000 doctors on board. So he’s an optimist. He especially believes that ePrescribing will be a decent intermediate step for those practices who realistically are not getting to an EMR any time soon.

Tony Scheuth, who I knew when he was hanging out at an original CHIN company called IMS in Colorado, is now a consultant who spends 80% of his time in ePrescribing. He thinks that pay for performance is maybe enough to push it over the top. But at the moment the incentives aren’t big enough (although he’s going to say that the dollars may be big enough in California & Mass). And then he went through the list of the P4P groups and how their incentives are often linked to infrastructure (or more accurately system use).

Of course the whole issue is that there is no financial advantage to the docs unless they’re at risk for the drugs, which 98% of docs are not.

So two optimists.  Perhaps they should both know better!  Or just maybe they might be right?

Rick Peters, who founded Oceania and has been around the health care EMR scene for a while, keynotes at TEPR.  He points out a few facts obvious to TCHB readers, costs are up–employers can’t afford health benefits  and so are dropping coverage and putting people into Medical and uninsurance slices on that nice chart from the California Health Care Foundation. And in the new high deductible world, costs are way too much for sick people. He didn’t mention Walmart by name but he and Paul Krugman are on the same page here….

He had a few other fastballs…

• Med malpractice is a red herring and premiums are are up because the insurance companies really screwed up that

• EBM: we’re not doing it but DSM may not save much money.  Finally under pay for performance, won’t the sicker patients be kicked out of the practice by the doctor?  So EBM may not be a panacea.  Because 80% of what doctors do is unnecessary, and 80% of these workups were done before.
• And I think he says (because his slides are horrible) that if we cut back to generic only drugs we’d save a fortune….physicians are not doing the cost effective thing.  And cant blame it all on pharma, 20% of patients who see the ad ask for it, but 70% of the time the doc will write the script/  Plus 60% of scripts are for off-label use (and therefore not EBM).

The result of all this is that we’re doing P4P and building the measurement systems for it. The  focus is getting measurements of what’s going on (and going wrong) not on getting the data that we need, and no ones forcing that on the system (no mandates).  Meanwhile admin overhead costs  physicians 40-60% of their revenue.  We know that EHR along can reduce office visits 9%, PCP visits 11%, and the % of members with 3 or more visits goes down 11% (all KP data).

So why ain’t happening? Generally computer technology is going to Internet based architecture and XML.  Why does health care think its different. Still opposing the adoption of these advanced techniques.  OK, so IT spending is higher elsewhere. But Wall Street spends limited amounts of its money on infrastructure–which it rents–and most of its money is spent on other advanced techniques like data mining.

We are preoccupied with duplicating the patient chart.  Peters thinks that a PDF alone would be good enough to move that data around.  We just need to get the data in useful form. We need that data in whatever form from whatever.  (By the way, for those of you with long memories this sounds like Chris Mayaud’s "physicians as short order cook" line that he was using in in 1997!)

Other artificial opposition — HIS v Amb record vendors; big institutions are not good innovators, but all the money goes to the big elephants. (He was pretty brutal about the IBM UPMC deal). Peters believes that innovation is coming in the smaller vendors integrating PMS/EHR.  But existing vendors cant switch to ASP as they’ll take a revenue hit.  So technology is blocked by business issues.

He thinks that ePrescribing is taking off. Although 99% of mail order/retail pharmacy is already automated. He thinks that SureScripts is driving this very quickly.  SureScripts is an utility infrastructure that is rented not owned.

Rolling this altogether (employer costs, Medicare costs, infrastructure we can plug into is there, tech development tools are better, OPM [Opium or other people’s money] is available if we want it) Peters thinks that we should go straight to revolution and chuck out the evolutionary phase that we’re in.