A Call To For Better EMR Software

Since I know that most of you don’t go back and see the great comments that are being made on older posts, I think it’s worth highlighting comments that are interesting and valuable. Here’s a comment that was made by Jeff Epstein which I think is a good call to action for doctors to reject those EMR vendors who are great at sales and marketing, but short on delivering what’s important.

This may have been true a few years ago (EMRs being hard to install and harder to use), but in 2009 EMRs have to be simple and intuitive. EMRs have to be easy to use and they have to be helpful. I don’t want an EMR that lengthens my day (2 minutes per patient lengthens my day by an hour) and makes my job harder! I don’t care about the payers and the government and the data collectors. I care about my patients and my ability to provide excellent care, document their care, write prescriptions and order tests, consultants and a plan of care.

There are many EMRs today that ARE easy to use, easy to learn and don’t cost an arm and a leg! We have to find these EMRs and purchase these EMRs. We have to reward this type of EMR and punish the EMRs which force us to enter data for the data collectors, thereby wasting our time or expecting us to spend hours of uncompensated time doing things that benefit others.

If your EMR does not save you time, you have a bad EMR. If you have to jerry-rig your EMR to get a note done at the point-of-care, while seeing the patient, you have a bad EMR. Bad EMRs will ruin our healthcare system.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.

51 Comments

  • John, totally concur with your assessment of what EMRs should offer for doctors. MD Logic has been documenting care for over 15 years and the first thing we talk about is providing doctors a better quality of life because we usually save them 1-2 hours per day – if you would like to know more let me know.

  • Agree with many of your comments but don’t know if the ideal matches what will and is already required for documentation guidelines. I suggest that an EHR that documents more, is able to accomplish all documentation within the timeframe of a patient visit, and captures all the approriate charges associated with the visit in the SAME time frame that you are accustomed to is more appropriate. With all the documentation guidelines and necessary associated charges, something that does this as a product of entry is much more efficient and cost productive than using time spent as the sole criteria of what defines a good or not good EHR.

  • Scott,
    It sounds like you’re saying, “Saving time is a benefit, but not the only benefit?” Am I understanding you right?

    I can agree with that. However, I’d bet that if every doctor that used an EMR could say that their EMR saved them time and made them more efficient, then we’d see massive adoption of EMR software.

  • EMR / EHR / and a lot of the software that is sold into healthcare entities throughout the United States is not always great stuff. Sometimes it is not even stuff, it’s vaporware that requires so much customization to get any of the great features that it is just not worth the pain of implementations.
    This is a condition that healthcare has brought on itself. I have watched for 30 years while hosptials and clinics and research organizations paid big money for what is essentially “crap”. And the main reason why is……”we’re healthcare, and we’re so special” among all of the industries in the world we are the special ones.
    So.. we are also willing to pay an incredible amount of money for poorly designed and executed product that does require immense amounts of custom implementation, and is really behind the curve in architecture and design that is available today.

  • Sam, there are over 400 EMRs currently available. If someone takes the time and makes the effort, they can find a great EMR. Probably 380 of the 400 EMRs are not very good. We (doctors and hospital administrators) MUST take the time and make the effort to find the good EMRs or we risk damaging our personal, local and national healthcare systems. Determine what you need and want and make sure you take your EMR’s of interest for a good, long, stressful “test drive”!

  • Sam,
    It’s just so amazing that healthcare hasn’t been able to create more standards of care and standards for documentation than they have. Each doctor and clinic seems to have their own style and that makes creating the software hard since everyone wants to be different for some reason.

    As Jeff says, there are some good ones out there though that find the happy medium.

  • Out of the hundreds of ways to “skin a cat” there are probably a limited number of good ways, a couple of “best ways” and lots of bad ways. The same is true of medical documentation. The variation is ok, to a point, but there are probably just a few “best ways”. Doctors are taught how to document during their training. It is not as different as people think. The best EMRs take the best documentation styles and make them electronic. A good EMR can take a poorly run office and make it a well run office in terms of chart management, medical documentation, scheduling and billing.

  • I’d say the call goes out to any EMR companies that aren’t producing great EMR software. Far too many to mention unfortunately.

  • Cheers to you for bringing this up! As the Director of Research for Electronic Ink, a design agency that has worked in the medical records space, it amazes me how often I hear people responsible for purchasing EMR systems lamenting about their lack of control over the systems they purchase. Complying with post-development usability criteria and changing the behavior of your users to work around the system are not the only options! A well designed system follows from a formally implemented design process! Check out my response to the recent HIMSS article regarding EMR usability.

  • Kevin,
    You make an interesting point in your response to HIMSS. Certainly many many many of the 300+ EMR vendors need to and should have thought about usability during the building of their software. However, Now that we have 300 to choose from, I think there is value from evaluating the usability of all these software systems. If we can assess which are usable and which are not, then we can provide some valuable information to doctors in the EMR selection process. Essentially they can avoid those that aren’t usable and use those that are. Does this not make sense to you?

  • There’s the rub, John. Software that meets a set of usability criteria (and we do this sort of thing all the time) is a necessary precursor to adoption but is not sufficient for adoption. The difference is issue of workflow support. Usability, as discussed by HIMSS, centers around best practices and guidelines. We should absolutely insist that screen layout be consistent, language be understandable and navigation be intuitive. The degree to which these meet a predefined standard can be determined on existing systems. Perhaps, developers will even make improvements. But determining the degree to which workflow is supported takes a very different skill set and is much more important to adoption. My point is, if something like workflow support is going to be a criterion against which the usefulness of a system is to be measured (and I would argue that the design of workflow support is the most important thing), do it before the system is developed and build to that plan, rather than measure against it afterward.

  • John – I would suggest two things:

    1. Healthcare organizations need to think about the degree to which an existing EMR systems needs to be customized to meet their needs (a task that may be better done by professionals in this field). They also need to insist on a frank response from vendors regarding the likelihood of this happening (ask any recipient of enterprise-level software how easy/difficult it is to have a system customized).

    2. EMR vendors need to move toward a product design and development process and away from the traditional software development process. This means following a formal design process that combines business & user requirements rather than developing to a set of feature requirements. Note that this can be done with existing products (not just new products).

    As the keeper of the keys (and the wallet), the healthcare industry wields enormous power over how vendors develop their products – more than it realizes.

  • John,

    Looks like I started a brush fire in the “Bill of Rights Section”. Its spreading fast.

    As to usability. The feds are now asking/demanding structure and structured data from an unstructured health care world. Tough bridge to cross.

    The next step I see from the feds is a re-structuring of the subject domain, not the currently installed HIT systems. HIT did the best they could with the tools, methods, platforms AND business models that were available to them.

    FULL DISCLOSURE:
    SL3 ambulatory EMR “on the runway”

  • Kevin,

    You are exactly right.

    Usability needs to include work flow!

    Maybe we need to define usability (it is all about making doctors MORE productive which means saving time and helping them be more efficient).

    Aexo dude (Brian?),

    If the structured data is limited and “meaningfully targeted” (has high value) then it is very manageable and can be accommodated in a system that is very usable. Structured data, if done correctly, makes the doctor more productive, more efficient and a better doctor (more complete and comprehensive).

    SRSsoft does a masterful job with scanning, writing, dictating and also capturing specific data in a granular, discrete manner and then displaying it for very meaningful use.

  • Great article by Kevin on “The Role of Design in the Design of EMR Systems”. I suggest you all go to his website, download it and read it

    That being said, I want to share a few quotations from his article.

    “The technology industry is led too often by technological innovation rather than by any understanding of human beings, their behavior, their needs or their desires”.

    “Through incremental cycles of evaluation and, refinement, the system is ensured to have been shaped accurately—not solely on the opinions of design professionals, but also on the needs, expectations and desires of the end-user audience.”

    “A successful system allows users to perform tasks in natural and intuitive ways.”

    “while still enabling users to interact with information in natural and intuitive ways”

    “the needs of the user and the demands of the situation”

    “So what is a good design? Design is a research-based, highly iterative process with a focus on exploring different models of the user-system interactions … coupled with fast, early and iterative usability testing … this ensures that the system is shaped not only on the opinions of design professionals, but also on the needs, expectations and desires of users.”

    “Introducing a formalized design process does just that. It enables the creation of a design that incorporates usability up-front, while ensuring that it fulfills the needs of users.”

    Kevin, great article! If you are going to design an EMR, you are exactly on point about the design process. That being said, I do believe that we have a number of well designed EMRs currently available. This has resulted from a few projects having the natural ability to design excellent EMRs or it is just chance that 2% of the currently available EMRs work in natural intuitive ways and meet the needs, expectations and desires of the end-users. Do we have intelligent design in the EMR universe or is it just chance that enables a small percent to survive and prosper (like organisms in the evolutionary process)?

    I wish the companies producing unusable EMRs would hire firms like yours to help them produce usable EMRs that improve physician productivity, are simple to learn, easy to use and affordable. I nice selection of better EMRs will advance the field tremendously as we unleash “natural selection” on a better cohort of raw material.

  • John

    We are looking at developing a user friendly, robust, efficient and inexpensive EMR solution.

    We believe in a bottom up and top down strategy. Where input is delivered by physician focus groups and acted upon by developers.

    Its a novel approach, build it with the end users needs and wants in mind.

    We are looking for physicians who might be interested in investing in such a system.

    Do you have any suggestions?

    Cheers

    Murray

  • Murray,
    That’s a really tough question to answer. There are 300+ EMR vendors and more of them being added every day (add your company to that list). So, it’s a hyper competitive market for people to be finding doctors interested in participating in this type of program. I have one advertiser on the right side which is doing something similar to what you describe right now. They’re bringing on beta testers to test their EMR.

    I know this isn’t much suggestion. I honestly don’t know how you start from scratch other than just pounding the pavement and talking to people face to face. It would take real trust in what you’re doing to do that. I’m also a fan of starting a blog as a way to instill trust in people. At least that’s what’s happened for me.

  • Murray,

    No need to reinvent the wheel. Find a good EMR that is already on the market and promote and sell that EMR. All the good EMR companies are looking to partner with people who can sell their product.

    If you know how to find the good ones, it should not take too long. Out of 400 EMRs there are a few excellent products already on the market.

  • The times they are a-changing. Today, to start a successful EMR company will cost a minimum of $5 million! (EMR technology has advanced) Between 2002 and 2003 there was a great flurry of new ones, many designed by doctors. Most are now failed, doctor designed from the grassroots is no guarantee of success. The new ones coming to market are mainly by billing companies who are adding the EMR standard features to tired billing software, no real innovation- me too’s.
    Just saying you want to be different is not enough because everyone thinks they are different. With that said, whether you like Medscribbler or not everyone admits it is different, and this is where we hope to finally revolutionize EMR adoption.

  • Definitely not reinventing the wheel, would be crazy to.

    I’m sure I’m going to ruffle a few feathers with the below but i believe it to be true based upon my 20 years experience.

    We are working with a physician who has developed his own so we won’t be starting totally from scratch.

    There are a lot of vendors out there but there hasn’t been much acceptance at street level in the N.American Market. I believe the numbers are 17% in the states and even less in Canada. In other countries its as high as 98%.

    To only have 17% of the market utilizing EMR says more about the quality of products available. True there are factors that are out of control of the developers but there are many in control.

    We’ve been supporting clinics and medical offices for a while. We hear a lot of complaints from physicians things like not user friendly, lack of quality training and support, poorly designed GUI’s and user interfaces, overpriced etc….

    I see this as more of a developer and manufacturer issue, poorly designed (usability and user friendliness), poorly priced and poorly supported. Many EMR’s are built by developers who don’t listen to their target market. This is not exclusive to EMR many development firms build a product for a market based upon their own conclusions. Not utilizing focus groups and panels to tailor their solution to the end users.

    We also have many years experience in the Games industry. Business development, software testing and engineering, strategic advice, development services etc…. An industry that lives and dies by ease of use, intuitiveness and functionality. From what we’ve seen so far these basics are lacking in many EMR solutions.

    Murray

  • Murray,

    How are you? We talked by phone yesterday.
    Get ready to see some “feathers” fly your way. 🙂

    As discussed yesterday, holler if AXEO can help with your dev efforts.

    — Jack

  • The financial strength of EMR is the recurring revenue streams. 5 million can be recouped with 500 -1000 clients in a 3-5 year period. Complete with a x times earnings on ones investment and a very solid exit strategy.

  • Depends the smart investor will accept less for something with legs.

    Took my first company public during the dot bomb via an RTO (reverse take over). Board of directors thought there was a better future in spread spectrum technology than gaming (Xbox, playstation etc…)

  • Murray,

    Lots of companies went public during the dot-bomb era.

    OK, show me the wire transfer for the first $3 mill angel or VC money that you get on ANY reasonable terms for a new EMR software dev company, and I will throw-in another $mill myself. 🙂

  • I am looking for assistance with problematic EMR software I obtained in Feb. 2009. I had obtained a subscription based EMR system, Dox Podiatry. Despite being an online/ASP model resident on the server of the software company the financial transaction was set up as a long term lease. Significant functional problems occurred with the software which slowed down my practice. Tech support was woefully inadequate. I decided to stop uitlizing Dox in July 2009. I requested that Dox allow me to sublease or transfer the lease to another prospective user. Dox refused and continues to refuse. As such I am making a payment to a leasing company for software I am not able to use. Dox is aware of my dissatisfaction but has not responded to my queries.

    Podiatry is a relatively small profession and, I feel, is often a target for unscrupulous vendors who realize that the profession is in a “thin” market.

  • Medscribbler, – Free installation, free training, free lifetime support (even for office printers, even the sales team is Microsoft Certified) and free data transfer. PLUS – do not pay until you are happy! Again Medscribbler sets a new standard. We have Medscribbler Cloud model (like ASP only thick) Plus you get our personal cell numbers. How do we do it? If you sell a product that makes people money then it is easy! Ed, I don’t know how long your contract is but if it is a year or two left and you are a lite practice (one office,one staff and 10 or 15 a day maybe we can work something out. Our goal is a realtionship – long term – make you money and you will actually be glad to give some to us!

  • Ed,
    Very sad story indeed. I’m not sure there’s any good answers that don’t involve you going and talking to a lawyer about the problems. These things get messy really quickly from what I’ve seen. A lot will depend on the contract you signed.

    One site I have seen recently is a site called Doctors in Peril (http://www.doctorsinperil.org/) (which also seems to be down right now). I don’t know much about the website/organization, but it looks like it’s a non-profit that tries to help doctors that are in your type of situation. Definitely has a bit of an ambulance chaser feel to it, but unfortunately stories like yours have been very common.

  • John,

    Not clear if Ed needs help with the lease issue or a replacement system, or both.

    In any event, we hear from a fair number of Eds or about to be, Eds, so we started a “We will be #2” plan. We realize some practices won’t rip ‘n replace for many reasons including the loss of face and political problems surrounding the realization they may have poured a TON of time and money down the proverbial drain.

    We can assist with a transition, or put a back-up system in place (#2), or even use the two in a combo.

  • I would like to thank all those that responded to my post. I had also tried the “doctorsinperil” website but it appears to be down. That is the type of organization I am looking for. Considering all the bad EMR systems that have been sold to healthcare providers, one would think that there would be some attempt at collective assisitance out there. Certainly, I am always interested in looking at new systems but my primary goal is to releive my obligation from a very expensive lease for a bad software system. Attorneys and lawsuits can cost a lot of money so it would be great to find an alternative. I perused the website for Medscribbler and Axeo. It is interesting to note the favorable monthly subscription fees for Axeo as compared to what I am paying for Dox. Currently, I am using a combination of transcription, pre-printed check off templates and a note making basic EMR system. For now, I am a bit hesitant to add new financial responsibilities until I have some guidance as to how to proceed with the current issue. Again, it would seem that there should be a lot of us in the same boat with similar needs. Looking at the bigger picture, this is an issue that need be addressed as I know a lot of practitioners out there who are apprehensive of obtaining EMR systems based on negative experiences of colleagues. We need to figure out who in the industry is wearing the white hats and who to avoid. Perhaps this forum can help. It is only one of two open forums that I could find dealing with such issues.
    Ed

  • Ed,

    I don’t know the folks at Medscribbler, but they sound like a great bunch that also want to help. I think it safe to say that neither of us wants to see a situation like yours. Bad for the HIT industry overall.

    What does the software vendor say? The “other side of the story”.

    I obviously would very much like to hear in detail (privately might be best) what went wrong that caused you to abandon a system.

  • ASP – web based has all your patient records mixed in with others on one server, is dependent on the load ASP EMR vendor puts on the server, makes getting records out sometimes impossible (AKA Dox) because it requires too much expense by the vendor, ASP is also dependent on the browser and its technology which was never designed for continuous form filling and input of medical records data.

    Cloud – also runs on the Internet, you own the server and is upgradeable as the business grows, there is no mixing of records, the “browser” not just the content management is specifically built for the task of medical records, you own your own patient records which are not mixed with others.

    Ed, don’t compound one mistake with another – run from Dox as soon as you can – the cost to them is $0 at this point – you are their cash cow – In most states a lease can be sub-let and the holder can not deny this if it is reasonable – ie, the person of the sub-lease meets the same credit conditions of the original. A $500 letter from a lawyer may end your troubles. I know we all hate lawyers but they actually do help in many cases. There may also be an out if they are not providing the support you contracted – a breach of condition that nullifies the contract. Or a countersuit for lose of business if they made any promises in their contract or sales pitch. A lawyer may turn out to be cheaper than the constant drip to your business.

  • Mike:
    Thank you; excellent advise. I have an appointment with an attorney next week. Also, thank you for explaining the difference between the ASP concept and cloud concept.

    Axeo:
    The vendor’s side of the story is that there are no problems with their system and that I am unwiling to spend the time working through their product. I had previously worked with five different EMR systems in different venues..office, clinic, hospital, residency program and VA System, all of which I had few issues with and learned fairly rapidly. I felt that 6 months of dedication to the Dox EMR system was more than enough time and effort. The amount of time I was placing in dealing with their system was deleterious to my practice by wasting financial and limited time resources. I really love evaluating EMR systems and am a bit of a techie so placing the blame on me was off base and inaccurate.

    Regards,
    Ed

  • Ed,

    Terms used interchangeably or in combination and often incorrectly or confusingly include:

    Infrastructure as a Service (IaaS)
    Platform as a Service (PaaS)
    Software as a Service (SaaS)
    Application Service Provider (ASP)
    Web-based system
    Cloud-based system
    Subscription model

    You can do a Web search or Wikipedia for a start.
    We work with a number of independent EMR consultants (with no horse in the race) that we are happy to refer.

    The umbrella IMO is Total Cost of Ownership (TOC). John also touched on an intangible in his recent post on data backups — he’s “worried”. Hassle, concern, worry, aggravation, lost productivity — all costs as well.

    We would still like to add your experiences (+ and -) with EMR systems to our knowledgebase. If you find some time, please email to emr at axeoemr.com. We promise not to try to sell you anything and we will keep all communications private. Thanks in advance.

  • Ed,
    Mike did give you some great advice. My advice is to find a lawyer that’s familiar with this type of problem. Software is a different world and you’ll want a lawyer/law firm that is familiar with this type of issue. Otherwise, it could be even more ugly.

    In fact, as I read your post I couldn’t help but wonder why more lawyers haven’t contacted me about getting in touch with doctors like yourself that have had issues with their EMR. It’s a big business and you are far from isolated in this happening.

    I can’t believe that the Doctors in Peril website isn’t up anymore. Although, it did seem like a front end for catching leads. A true forum to talk about doctor related issues with EMR would be an interesting thing.

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