The following is my letter-to-the-editor comment for the article "EHRs: What the Allscripts-Misys marriage means to you":
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There might be a small error- doesn't the "EHR market" include mostly CCHIT certified systems whereby the "EMR market" include all others? According the Medical Records Institute, the "EHR" definition includes "interoperability", which is the main reason to being for CCHIT. Thus there are about 100 EHR software vendors, all the rest being the generic "electronic medical record" (EMR). In the future this may change, and for now one would be hard pressed to call even CCHIT certified EHR systems "interoperable", but this is how things stand for now.
BTW, you're not worried that continued consolidation will end up with less competition and thus higher prices? Your point on the complexities of the marriage is well made. Overall, I find consolidation to be a bad thing for the long term.
------end------------ URL: http://medicaleconomics.modernmedicine.com/memag/article/articleDetail.jsp?id=505442
Yeah, I know that he doesn't post most, and lately none of the letters-to-the-editor, but they get posted here where the most intelligent readers reside! His loss... emrupdate's gain. I'm like a preacher in a street corner talking into the wind...
Al Borges, M.D.
● Oncologist in a Small Group Practice in Virginia
● My website URL: http://msofficeemrproject.com/
For all intensive purposes Interoperability is failing except in specific situations. The problem is that there exists no generic free way for Physicians to do it.
The answer my friend is in the PHR, which can by definition of its players and the patients access to there own records provide a portal and data warehouse that the patient can provide information to all providers.
The only other choice is some centrally located Physician and Provider transfer Data Warehouse Site, and this ain't happening.
Therefore, CCHIT certifed or not, EHR's, which regardless how the industry wants to rename it from EMR's, will fail to live up to this expectation, even if they do incorporate a perfect system to interoperate. This is because by the very nature of charging for interoperability you will turn off 30-50% of the practices/providers. Therefore, you are stuck with a hole in the system, one that is critical to really attain interoperability.Bottom line, this is complex, and until CCHIT requires free interoperability with a configuraton manager for this interoperability in every system, with no charge to go-live with a interface of this nature, it will fail. IT needs to be configured and used by the practice/hospital/asc/home nurse everyone in a manner that does not cost a fortune.
Todays world. RHIO wants to implement a Interoperable Record. First they have to choose one or a few vendors and get them to play together. This can be negotiated upfront but has a cost. Patient goes to hospital, interoperable record available to Ambulatory Care Provider via interface, Home Nurse can access records via remote access maybe or have to have a interface to there own system, ASC has access to and can update record.
Cost for above, no less then 50K more then likely up to 100K or more. This is for one RHIO implementation. How the hell is CCHIT or anything of this nature going to succeed if it requires everyone to buy interface technology. These costs don't include the actual Maintenance which could also bd 10K -30K a year after the interface is up. Ironically, there is no maintenance on a working interface as it rarely changes.
Its all bullshit, it drives me crazy. It has been the case for over 20 years and it is not going to change. To many people want to make money on this dream to ever turn it into a reality. This is one of the few subjects that I feel passionate about a change in direction is needed. Take the capability out of the hands of the big EMR's below and move it to the PHR. Patients do this now, they bring there records. It would be a lot more easy if patients at check-in have a standard to import the records to any system anywhere in the world.
I have a design for such a system that would include Transaction Integrity and the ability to know what has and has not been transported to each EMR.
NO MATTER WHAT ANYONE SAYS WE ARE NOT TALKING ABOUT COMPLEX DATA HERE, UNLESS WE TRY TO RESOLVE ALL THE ISSUES AROUND DATA INTEROPERABILITY, LIKE TERMINOLOGY AND THE LIKES, BUT THAT SHOULD BE VERSION 4.0, RIGHT NOW WE CANNOT GET PAST VERSION .05. WE NEED TO START SIMPLE.
Brendon
Brendon,
You and I agree more often than we disagree. I agree with much of what you say re: interoperability.
Some entity must place pressure on the vendor to do it correctly. I don't want the governement doing it because we'll have more of what we already have.
Case in point: A new customer wanted the practice's encounters transferred from their former EMR to Medtuity. The former EMR had an advertised "CCR interface". The problem was, as you might guess, the CCR interface was all but unusable. It was so lacking in valuable data as to be useless. We were forced to put much greater effort into the trransfer of data than we should have. That work was through learning the former vendor's database schema and brining in the information through an interface that had to be programmed.
When you mention interoperability, I believe a sizeable number of vendors quake in their boots because interoperability also brings with it the ability to switch vendors. Even among those dying EMRs, their customers can't easily switch vendors and thus, the dying company continues to receive significant maintenance revenue.
By the way, for a blatant plug, Medtuity has programmed the full CCR spec for both import and export. Any encounter can be exported with a high degree of fideility for the "lists"- problem, meds, allergies, family history, social history, as well as surgery and procedures. All lab results are reported as well. The CCR unfortunately does not include the history and exam portions of each encounter, a significant failure of the CCR as an interoperability tool but the pressure is certainly mounting to include that because, frankly, there is no other means for transferring the information. The CCR was designed as a "snapshot", but its structure is well enough liked in the industry that there is pressure to use it as "video" (>1 snapshot) and to make the snapshot more inclusive. Fortunately, that step would not be difficult for the CCR.
I believe Brendon is on to something when discussing a PHR. Perhaps enough pressure will develop from the patient sector to force vendors to facilitate the electronic pooling of their records into a single source. In my recent experience with a family member suffering an illness, it certainly brings to light the need for the ability to easily review records from multiple sources.
mchasemd: Brendon, The former EMR had an advertised "CCR interface". The problem was, as you might guess, the CCR interface was all but unusable. .... a sizeable number of vendors quake in their boots because interoperability also brings with it the ability to switch vendors. Even among those dying EMRs, their customers can't easily switch vendors
The former EMR had an advertised "CCR interface". The problem was, as you might guess, the CCR interface was all but unusable. .... a sizeable number of vendors quake in their boots because interoperability also brings with it the ability to switch vendors. Even among those dying EMRs, their customers can't easily switch vendors
Guys,
Scriptnetics, the parent company of Medscribbler, also makes software for other companies, most of what we do is related somehow to medical or marine biological research. For the interopertabity argument I am sure you know but have gotten too close to the argument - that there will never be interopterbility because it is in no company's interest to do so. An example that is simplier and been around longer than what we are talking about now is the Dicom standard. This was a grassroots movement that actually was a "standard" at one time. Now there are dozens of dicom formats. So what happened, all the x-ray machine companies started to "tweak" the standard, probably so you have to buy only their other systems if you want "interoptabity. So now you have the problem (we write Dicom software) where the major companies; Philips, Siemans and GE have their own Dicom format that is enough different that special interfaces have to built to more "generic" standards. So, for example, if you have a Philips x-ray machine if you consider another machine then you are looking at a special interface or even worse changing you HIS or other software - so you buy Philips because it is cheaper even if pay 30 or 40% more for the machine in the first place. So what we have is a standard that has been "bastardized" in an attempt to limit competition by taking success in one market and using that strength to compete, unfairly in my opinion, to keep others out of peripheral markets.
GE is now doing this in the hospital market - rather than building to the standard HL7 they have their own so they push their HIS as being the only one that "interfaces" to their machines.
The only solution if we want interoptablity is strong government action, unfortunately there is a four year cycle to action in Washington and the law on lobbiests (sp?) special interest groups has to be changed first. Otherwise we get what Ccrap was - vested interests, HIMSS driven (a private corporation with fees and structures making a group to keep those who don't agree with them or who might have challenging technologies out of the market)
Medscribbler Getting you there sooner!
Scriptnetics
866-350-6337
>>Todays world. RHIO wants to implement a Interoperable Record. First they have to choose one or a few vendors and get them to play together. This can be negotiated upfront but has a cost. Patient goes to hospital, interoperable record available to Ambulatory Care Provider via interface, Home Nurse can access records via remote access maybe or have to have a interface to there own system, ASC has access to and can update record<<
How will this be paid for? Suppose the infrastructure were created and allowed for physicians to send data to the system/retrieve it. Who now maintains it? What happens when there are duplicate records for one patient (ie., a provider only sees half the record because the other half is filed under "another" Jane Doe)? Who will be held responsible for that? The sender or the dept. maintining it? What happens when there are updates? How will the interface be tested with every vendor after the updates?
>>NO MATTER WHAT ANYONE SAYS WE ARE NOT TALKING ABOUT COMPLEX DATA HERE, UNLESS WE TRY TO RESOLVE ALL THE ISSUES AROUND DATA INTEROPERABILITY, LIKE TERMINOLOGY AND THE LIKES, BUT THAT SHOULD BE VERSION 4.0, RIGHT NOW WE CANNOT GET PAST VERSION .05. WE NEED TO START SIMPLE.<<
If you're just talking non-discrete data it is not terribly complex data. But, a RHIO has to have very strict structure to the storage requirements. You don't want some keyoard-intensive EMR populating data from one of their text fields into an inappropriate section of the PHR (or other medium) hosted by the RHIO. I'm not talking interoperable data. Just an easy, logical format so a physician isn't cursing the system because he cannot find the results from Jane Doe's last exam (maybe something as simple as trying to see what the last ROM was in her knee...are symptoms improving/worsening?) There has to be a simple to follow format so the standard operating procedure for using the system isn't 1.) Review previous health history in their system, give up then 2.) Call the initial office to have the records faxed over so one can read what the chart really contains. Some structure is needed in data before any RHIO becomes useful. EMR vendors would have to step up their development in structuring their data.
How can one integrate medicine, make informed decisions and take better control over healthcare without sharing data in a logical format? How can physicians really understand who their patient is? Again, forget interoperability right now, just think of usability.
How do you make continuity of care easier? Give physicians an intuitive interface to look at and read the notes from 1, 2, 3 or any number of referring physicians. Some amount of structure is absolutely required for this. The PHR is a nice start, add in a standard for medications (NDC?) and labs (LOINC?). HL7 interface will be needed so the CDA should be adopted by EMR vendors who are serious about electronically sharing data.
Al, can you devote a little of your energy to soliciting the NIH for money? It could lead to a better HIT landscape. Do you want to be a roadblock to implementing HIT systems? Or, a catalyst? Physicians aren't demanding PHr's, RHIO's or CCR/CDA, hospitals largely ignore the problem (they'd rather the patient just come to them for all their medical needs) and vendors have to charge exorbitant prices to cover their development cost to the few who demand some type of interface (CCR or CDA).
So yes, "version .5" should be communications between vendors so we can test out some very simple exchanges of data. I personally contacted a number of vendors and received virtually zero response. So, like the collapsing housing industry asks...should the recent collapse fall on the shoulders of the lenders, borrowers or backers of loans? In healthcare, is it the lack of demand from physicians, lack of financial backing or lack of vendor development to blame?
Actually Brandon,
On this we disagree. What you are trying to accomplish is the holy grail. As I said Version 4 or 5 should get to this level, maybe. Patient entered from a paper chart into the PHR, or the actual scribbled paper being transportable would be a huge step in the right direction. Even in this RHIO environement there will be many Physicians that simply are not on board and don't plan on it. If the Neuro Surgeon says go screw yourself to the IT initiative forced by the Hospital they have to say OK we will. Where the hell do you get another Neuro Surgeon, or Vascular Surgeon for that matter. Dr. Lamas, one of our customers is the only Vascular Surgeon for Hialiah Hospital, Palmetto, and two other facilities representing a populous of nearly 300,000 - 500,000 people. Who do you think really will run the show, the Hospital or the Physician whos services they have to have.
I understand Medtuity has a great system for coding at the granular level, but even you don't have a terminology set that is universal, nor really portable from place to place. If you do it is your own standard as you see it to be desired. I am not saying it is not good, what I am saying is we are a long way from this level of Granular Data (Your Words) being captured by all care providers.
Ironically, eMedRec, the so called non-granular EMR is anything but, we capture all kinds of Data, at this point after 5 years of EMR/EHR development I actually would conclude we are more a Granular EMR solution that can be run as a Enterprise Document Managemente Automated Record System, a Voice transcription system, or as a full fledged data record like all other EMRs. T
That being said, we are nowhere near ready to join the long consortium of vendors looking to promote there own standards and dictate them down to everyone else. This is a lose lose solution for all including our country most importantly.
First and foremost, for many Physicians much of the data one person needs in there care of the patient is not needed by another. Therefore, there will always be holes in the data.
First you build the foundation, sharing of patient records in whatever format between systems. I.E. if you use CCR capable EMR to store Problem Lists and Medications and you or your provider gives you digital copies of your physicians notes and labs, when you go to your specialist, have a car accident while traveling Rome Italy, or simply get really sick in Ecuador, visit your PCP, all of this data is in your PHR and available for all to see. That is called Interoperability, plain and simple, version 1.0. In it you will have codifed medications, you could have codified problems, and you could even have descriptions of the problems in the comments section. You would also have health summaries and last EKG, ECG in any number of formats.
Maybe version 2.0 it says, Physician Entered and not edited by patient, or some other method to show the source of the data, for those Physicians who don't want the patient to edit all the data.
I understand the need for holly grale approach, but this will never even get past a RHIO, never mind a National or International Implementation of the technology.Lets be very realistic about the current state of health care and make realistic goals that we can build upon.
As to your response to vendor to vendor communication, get used to it, it ain't happening. I wish and dream of it and have been fighting for it in different ways for over 10 years, even with just a very small local community here in my neighborhood. Ain't happenin, less then 30% physicians on EMR, less then 20% more going to add in the next 5 years. Incentives to buy are actually on the decline. I as CEO of eMedRec will make a statement, on the record on this: "I will not spend months desiging ineroperability interfaces that are worthless without a true demand on the part of our customer base."
Better have a way to move this now and grow on. PHR = This way as best we can. A scribbled on Note, patient is allergic to penic... is better then no note at all when that hospital in Rome is looking up the patients history as per the permission sheet in the wallet or a love one.
I wish I could have different dreams, but I simply cannot on this matter.
Matt,
What do you expect for a software that costs $995 per physician.
Maybe I wasn't very clear...IGNORE INTEROPERABILITY FOR NOW. (please don't take offense to the CAPS. I want to make that point clear)
Structure data to the point so that when a family practitioner inputs "patient is allergic to penicillin" the EMR understand "penicillin" is an allergy. Not a general piece of text listed in the progress note. When an endocrinologist inputs sulfonamides as an allergy the "middleman" (the PHR, CCR or CDA) understands this is an allergy. When they put in the allergic response it is understand as a response, not another allergy. Again, throw out interoperability for now. If the EMR receiving the penicilling allergy does not recognize it as "penicillin" -only an allergy- then an adverse reaction popup will not occur when they write an Rx with penicillin. Users will scream for more interoperability. Vendors need to take this one step at a time. ADD STRUCTURE TO THE DATA.
Again Brandon,
It would be nice if and only if everyone could determine what is that structure. Some portable information to start is better then none.
I think we will be forced to interoperate, and it will not be the Government or the Vendors, who obviously suck at this. It will be the consumer and the norm for them to use the PHR to transport records.
It is the only way we get there. When we do, then steps will evolve to make this a reality in more codified methods.
I pray the consumer forces this on us, otherwise we are limited to our conversation here.
Take care my friend.
Brendon:It would be nice if and only if everyone could determine what is that structure. Some portable information to start is better then none.
That is already done...PMH, SH, meds, allergies, labs, surgical hx and demographics will transfer to and from an EMR via CCR/CDA. We just need more doctors to purchase EMRs with this type of interface!!
Brendon: "Matt, what do you expect for a software that costs $995 per physician?" (in regard to a dismal CCR interface by that vendor.)
If a vendor advertises that it has a CCR interface, there is some responsibility to have one that works....that has some modicum of usefulness. While riding on the coattails of the CCR has its benefits, it comes with responsibility as well.
That is my expectation.
Hi Brendon:
>>> It really needs government intervention. I know AL you hate this concept.
Actually, I've said before that if big government really wanted a certification process to work, they should have done it themselves and made it super-affordable.
What I don't like is for big government to bastardize the use of EMRs in unproven, unnecesary, and demeaning efforts like P4P and eprescribing.
>>> Its only a matter of time before even the larges companies feel it, many already have.
Did you not read the thread here, and how the count of CCHIT-certified EHR companies with financial problems (including massive declines in their traded stock) has increased: http://www.emrupdate.com/forums/t/13444.aspx ?
>>> Not because of Al's continous attacks on it here, which is very interesting but hardly going to move an entire political system and billion dollar industry one way or another.
See new thread located here: http://www.emrupdate.com/forums/p/13717/81351.aspx#81351
Hi Brandon:
>>> Al, can you devote a little of your energy to soliciting the NIH for money? It could lead to a better HIT landscape. Do you want to be a roadblock to implementing HIT systems? Or, a catalyst?
That's not really fair. I'm a programmer myself, and like you, want HIT in the USA to succeed, but in a different manner. As a practicing physician I want costs to come down and for EMRs to become better in ways that can truly improve a practitioner's life, like through interoperability, through improvements in workflow, and possibly even through a real ROI.
I don't want third parties to use "EHR" softwares against practitioners in schemes to decrease our incomes and make us work harder and pay for increased overhead.
BTW, I did part of my fellowship at the NIH and back when I was there (1989/90) they were flush in money. Not now...
Cheers,Al
alborg:As a practicing physician I want costs to come down and for EMRs to become better in ways that can truly improve a practitioner's life, like through interoperability, through improvements in workflow, and possibly even through a real ROI.
I think you can be a catalyst for HIT implementation. But, I can't remember the last time I read a positive post from you about HIT. You've programmed your own EMR that is free for download, yet the only advertisement in your signature line is a link to download "What's wrong with the direction of HIT..."
Why not spend time educating people on your EMR? Develop the CCR or CDA within your own product, build an HL7 interface to lab companies or other necessary components to improve workflow. It's a lot of work, maybe work with another "open sourcer" like Graham or Fred to speed things up, combine resources/knowledge, etc. You could write an article about what's right in the industry, where to download the "right" free software or something that pushes the industry forward.
Do you keep in touch with anyone at the NIH these days? It would be nice to have a contact there.
Matt & Brendon:
Judging by the $995 price tag, you are both obviously referring to Amazing Charts above, which is the EMR I use.
As regards what you get for the price, the answer is that you get the same lack of interoperability that you get for ten times that price with other systems! (At least that's what I seem to read here).
Matt, I am a bit confused by your post above. Once again, this may be due to disagreements about standards.
The definition of a CCR, as I understand it, is a portable "snapshot"of a patient's health data, which would include patient demographics, insurance information, diagnosis and problem list, medications, allergies and care plan. It sounds like you may have redefined CCR, as it relates to your product, to include some other features (?).
Amazing Charts absolutely allows you to export a CCR, as it is conventionally defined, for each patient, or for all of your patients, at the click of a button. They can be printed, or exported in XML format.
Furthermore, if I want to provide the patient with a more comprehensive health record, one more click prints the patient's last note, or all their old notes. Since each printed note, by default, contains all past medical, family and social history, this provides a fairly comprehensive summary of the patient's overall health. Certainly, with Amazing Charts, I am now providing my patients with much more than I was providing with paper charts (and that's the other thing I get for $995).
In reference to your client's conversion woes: this is regrettable, but I don't see what conversion of old encounters has to do with the CCR.
For the record, if you want to export old clinical encounters, this is extremely easy to do with Amazing Charts. Just click "Export Patient Encounters" under "Administrative Options". This exports all past encounters into a nice, simple Excel file with explanatory headers. It's not even password protected.
Your client might not have known about this, or again may have been confused by differing definitions of CCR vs. past encounters.
Brian Cotner, M.D. - Family Practitioner First Amazing Charts Users' Conference Branson, Missouri - June 20-22, 2008
>>> Why not spend time educating people on your EMR?
It's functioning well inside my office where everyone seems to work with it well, giving me the best ROI. It has an excellent 150 page instruction manual which I'm currently rewriting.
I've also rewritten the MS Word EMR Project; I'm working hard at documenting it and tying up the loose ends.
My primary energy is to provide care to my patients, and to that end I'll argue against any force that threatens my ability to do so, including CCHIT, P4P, and eprescribing.
>>> You could write an article about what's right in the industry
Much of my writings is focused at trying to mold those forces that I perceive are threatening to destroy my medical practice, through HIT. I do spend a lot of time writing technical articles and helping others in programming s.a. in the MS forums and in other blogs. Generally I write more than 99% of internet users, and I write a lot. Here I'm a 3700+ poster; at Sermo I'm in the top 1% of posters (they tend to rate you on quality, not quantity ). At the AC forum I'm also a prolific poster, considering the fact that I post there because of the personalities there and the fact that it's a software very similar to what I use. At Medical Economics I'm sure I'm one of the most prolific letter-to-the-editor writers, considering the fact that Mr. Lowes doesn't post them up since he seems to ignore anyone that disagrees with him. I could go on- but you get the point. I write especially on a reactionary level, a technical level,and at a level of friendship and support with those that I agree with. Scr*w the industry- these levels are much more important.
About the NIH- I do have some contact with some fellow physicians, but it's been a long time since I've called on them.
Cheers,
Al