Guest Post: Healthcare’s Challenging with Meaningfully Using an EMR

Tom Chernitsky has over 15 years experience in the fields of Document and Information Management. He is currently President of File Management Solutions, LLC, which offers a variety of solutions for helping Practices digitze their paper files to be linked into an EMR system.

As we SLOWLY progress towards the Government putting in place an actual plan to fulfill the goals set forth for Healthcare in the American Recovery and Reinvestment act of 2009, the backlash seems on the verge of overtaking the talk of actual good that would be achieved.

Perhaps it’s because without a clear plan, everyone has had the opportunity to focus on the negatives. Maybe it’s because many think that by the time a plan is in place, it will already be 2020. Or it could just be the general fact that no one likes when the government mandates change.

The fact is, the HealthCare Industry is one of the few remaining industries that seem to be intent on believing that a paper based system of record keeping is superior to an electronic one. Whether it’s a one Physician Practice or a large chain of hospitals, the fact that patient records are still in paper form, and so many believe this is still the best method, indicates the enormous challenge faced in succeeding in meeting these goals .

Let’s first look at the large clinics and hospitals. Any of these organizations that are still on a patient based record system undoubtedly use a variety of computer applications for billing, payroll, inventory, accounting, Human Resource, etc. Why? Because it works better and more efficiently than filling file drawers full of paper. It saves money, adds to the bottom line, and all and all makes life simpler for all involved.

To think that the same isn’t true with patient records is to believe that Healthcare is so incredibly different than every other “business” in the world that technology couldn’t possibly help them. Yes, Healthcare is different, but every industry that has made the change in the past 20 years has said the same thing. That’s why there are industry specific programs and platforms for each industry. Are they perfect? Of course not, but most are far more efficient than rooms and drawers full of paper records. And there probably isn’t an industry that has made the switch then decided after to ditch the digital and go back to paper.

As for the burden of meeting Meaningful Use criteria being too stringent for small practices to meet, this is again an excuse to avoid change. While some of the criteria may be excessive, overall it will be a roadmap to what practices have to do in order to use an EMR system in a way that actually provides the benefits it is designed to provide. Buying an EMR system and using only half the features will undoubtedly lead to the system not generating the ROI it is capable of providing. Being forced to meet Meaningful Use is a way of ensuring offices are using their EMR system in a way that will provide them with the benefits it is designed to provide.

No other industry has received the funding and support to make this transition that the Healthcare field has at their disposal. Perhaps many Physicians are unaware of exactly what is available to them to aid them with this transition. Most of the talk is about the money received for meeting Meaningful Use criteria. In fact, that is probably the least of the benefits.

The Regional Extension Centers are assembling teams of vendors to assist along every step of the way, which means it’s not just an EMR vendor plugging in a system, giving a bit of training, then walking away saying “good luck.” The REC’s have received a tremendous amount of government funding to ensure they provide the services they are supposed to provide. There are ramifications involved for those REC’s that do not meet their goals, giving them incentive to provide the services they have been tasked with providing.

Change is never easy. If it is, it’s probably not enough of a change to have much impact. These are big changes, and there will be many stumbling blocks along the way. But in the end, even small practices will see increased profits based on a more efficient system, while at the same providing patients with better all around care. It will just take some time, and the understanding that sometimes change is good.

I always love when smart people are interested in doing guest posts on my blog. They offer a different perspective than what I offer and I think that’s great. I definitely don’t have all the answers and there’s always a number of different viewpoints on every given situation. If you have something interesting to say or an opposing viewpoint feel free to drop me a note.

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.

24 Comments

  • “Change is never easy. If it is, it’s probably not enough of a change to have much impact. These (EHRs) are big changes, and there will be many stumbling blocks along the way. But in the end, even small practices will see increased profits based on a more efficient system, while at the same providing patients with better all around care. It will just take some time, and the understanding that sometimes change is good”.
    Wow, this is a profound statement. Applies to many industries and situations; more importantly aptly describes HealthIT’s forced shift towards efficiency and transparency. As rightfully said, challenges and road blocks are certain; embracing the changes, understand the nuancess, keeping at it and encouraging the staff to live through the workflow changes are some of the key ingredients to make EHR implementations successful.
    Very nice post; straight talking.
    Thanks

  • Thought on why the EMR effort is proceeding so slowly:

    1) EMR is much more complex than a simple inventory control system. The “human resources” apps probably come closest to the mark, but there are hundreds of separate HR apps out there, but they don’t have to talk to other HR apps.

    2) Government is not good at organizing complex efforts. The government-sponsored HDTV effort took some 30 years to implement, and the results were largely irrelevant in that we’d moved beyond the concept of “broadcast”.

    3) The medical community has no “IEEE” standards group to represent their interests and get various vendors to pull together towards a well-defined goal. The AMA could maybe assume this role, except that it is mostly a political organization, with only 17 percent participation by physicians.

    4) Large medical groups are not likely to encourage mutual cooperation in EMR development. To them, small physician groups are competition. (Likewise, Sarbanes-Oxley works to the benefit of large corporations who can afford the accounting red tape, to the detriment of Mom-n-Pop organization, where red tape is a meaningful expense.)

    You can’t just throw money at the EMR problem and mandate results. There has to be an organized effort that works positively and doesn’t rely on coercion. Help seems to be nowhere in sight.

  • Found aspects of Mr. Chernitsky’s original post to be very enlightening …

    “The REC’s have received a TREMENDOUS amount of government funding to ensure they (vendors) provide the services they are supposed to provide”.

    So let me get this right. Providers have to provide documentation of their meaningful use to receive partial reimbursement for implementing an EHR which may have limited benefit for the practice.

    YET … RECs are paid up front by the government to be consultants and broker solutions for EHR vendors to sell their system to a practice … without those RECs having to demonstrate “meaningful value” to those practices in order to receive their government largess?

    Mr. Chernitsky’s further comment that…

    “There are ramifications involved for those REC’s that do not meet their goals, giving them incentive to provide the services they have been tasked with providing.”

    … is an empty comment when he fails to define those ramifications and fails to justify what essential value the RECs will provide that providers and EHR suppliers can’t resolve directly more effectively.

    RECs are simply brokers who have suckered the government bureaucracy to pay them up front … when paying the providers up front would have provided better results.

  • dkberry,
    I think the RECs only get part of the government money up front. Then, I think they get more of it as they hit certain milestones. I could be wrong, but I believe that’s how they’ve structured the “funding” of the RECs.

  • John…

    Why do the RECs get any money up front. Like brokers in other industries… all they need to do is earn their credibility by matching providers and vendors resulting in “meaningful use”.

    If it’s okay for providers to have to wait to gain the advantage of partial reimbursement for their EHR system then the same incentive would be there for RECs to provide “meaningful value”. Why would they need to be paid up front?

    Mr Chernitsky provided up front the fact that his company provides document linking to a practice’s EHR. While I agree with him that the absence of a plan would impede adoption … but both the positives and negatives would be apparent from the outset. Further … who would benefit from the negatives being realized? Perhaps those negatives actually will adversely affect the practices mandated to adopt EHRs?

    What is illuminating is that the HITECH Act is incorporated in the ARRA … i.e. The Stimulus Act … doesn’t “stimulate” health care providers … it “stimulates” EHR vendors … entities formed to be RECS … and companies like File Management Solutions LLC. All of who will be paid up front and receive the full cost of their services reimbursed … unlike the health care providers themselves.

  • The RECs wouldn’t exist if they didn’t get the money up front. For the most part.

    Just because the meaningful use money isn’t up front doesn’t mean the REC money shouldn’t be up front. In fact, maybe it’s a good argument for why the meaningful use money should be up front for doctors too.

    Either way, that’s not going to change what healthcare has been given. The question is still out there whether the RECs and meaningful use will have an impact for good or bad. Seems like such a waste to have $18+ billion go to waste or even worse, to cause harm.

  • John…

    “maybe it’s a good argument for why the meaningful use money should be up front for doctors too.”

    BINGO.

    You yourself counselled practices that EHR implementation ought to be undertaken by a practice for its own reasons not for the government’s incentive payment for meaningful use. Providers are that smart too … so meaningful use will have zero positive impact on providers. RECs may help but only as a broker.

    I don’t think large entities such as Mayo, Cleveland, Brighams, and Intermountain think that $18+ billion will go to waste. They just aren’t worrying about anyone other than themselves and if they suck up all $18bil … oh well. Too bad.

    OFF TOPIC … but relevant to the concept of EHR incentivization. I assume that everyone realizes that in the UK the ENTIRE private practice PCP system under contract to the NHS all implemented EHR from one of less than a handful (not 300+) vendors … without government mandate … and without NHS incentive payment. (See EMIS http://www.emis-online.com/about-us/company-profile/) The UK NHS secondary care system is the component that has failed to implement EHR nationally … even though they are all operated by the same provider and have identical operating systems … like our VA. Go figure. A failed government EHR implementation plan.

  • lol….Great quote Bobby. I’m adding that to my slides for talking about resistance to change in EMR adoption.

  • dkberry,
    Hopefully what the REC’s will be providing will be trusted resources that practices can call upon to help them meet Meaningful Use standards. With so much money involved, there must be some sort of entity to vet who is working with these practices.

    In addition, there is nothing that stipulates that anyone must work with the REC’s, or any of their vendors, in order to achieve meaningful use. It is a service being provided to help those practices that don’t wish to go it alone in this process. Physicians can chose to work with whomever they chose, even if they aren’t affiliated with their REC.

    File Management Solutions is not affilitated with, partnered with, nor a preferred vendor of any REC. While it would certainly benefit my company, it is currently not the case. I just believe that the system in place, while not perfect, is the best possible solution.

    Dr. Blumenthal wrote a very intersting letter just last week about the fact that different practices are in different stages of progression. The link is here:
    http://healthit.hhs.gov/portal/server.pt?CommunityID=1959&parentname=CommunityEditor&control=SetCommunity&parentid=52&in_hi_userid=11673&PageID=0&cached=false&space=CommunityPage

    There is no silver bullet to ensure this process goes smoothly. I, however, believe that the REC’s are the closest we will get to a system that provides help for those who want it, without penalizing those who chose to go it alone.

    Tom

  • Tom…

    Neither RECs nor vendors can guarrantee a practice that its system will meet “meaningful use”. With “so much money involved” (not just the $18+ billion incentive funds … but the billions more from practices and secondary level HCOs implementing HIT systems. What is guarranteed is that there will be fraud, waste, and abuse horror stories with practices bearing the burden of having to pay for failed implementations by a vendor who goes out of business … and then finding out they can’t get reimbursement.

    Practice ownership will always be where the buck stops. Most practices do not have IT staff and will need outside consultant help. I’d pay a qualified EHR consultant who works for me. No way would I employ a REC who is not working for me but working for the government and is paid based on meeting government implementation milestones that DHHS establishes. I wouldn’t want a REC guy anywhere near my practice.

    As you reported I understand File Management LLC is not CURRENTLY affiliated with any REC although it would benefit your company if you were.

    RECs are simply government paid brokers unable to guarrantee the quality of a vendor’s offering … how well those products will meet the needs of my practice … whether that product will meet meaningful use criteria … and whether the vendor is around next year to support the system we paid for.

    Only entities making money out of the government mandate for EHR to subscribing practices are software vendors and REC brokers.

  • Tom… sorry one more thought based on one of your final statements in your original post:

    “But in the end, even small practices will see increased profits based on a more efficient system, while at the same providing patients with better all around care.”

    What are your facts to support the contention that ERH will increase profit through improved efficiency? What I have direct experience is that EHR implementation reduced the number of patients our practice could see. Making a case for EHR through practice level efficiency gains is academic theory.

    We need increased primary care capacity in America… but with practice panels full and seeing 4 to 5 patients an hour … there isn’t much room for an EHR to grow the topline. If it doesn’t grow the top line … it fails the business case for adoption.

  • DK Berry,
    The possible value for doctors I see coming out of the RECs is likely going to be the group purchasing power (assuming you want to buy the REC negotiated EMR) and hopefully some high quality vendor neutral information. I along with a number of other people are working with some RECs on ways to provide some vendor neutral, independent EMR related information to the RECs which they can then pass on to the doctors. I think this could be tremendously valuable. We’ll see how many of the RECs follow through with this kind of offering.

    I think there’s a case to be made that EHR can make a practice more efficient. I’ve seen it in a number of cases. That said, I’ve also seen it make some practices less efficient. That’s why selecting the right EMR and implementing it well is so important. You don’t want to end with a less efficient practice.

  • John…

    Group purchasing power? If there are 300- 800 vendors… why do we need to group dissimilar, different owned practices to get a better deal through a REC bundling?

    Do HIT experts believe there is potential for RECs to bundle several practices into a common EHR vendor solution?

    As diverse as practices are by specialty and subspecialty in group or solo practice … how will post sales implementation, training, and software modifications to fit the needs of the client be handled?

    You say you have seen EHR result in more efficient practices and in other cases less efficient practices. I am more concerned with practice EFFECTIVENESS … not efficiency. Efficiency is more a factor of a how a business operates within outlined best business practices. The efficiency of a business helps define its margin… not its top line capacity growth which is its operating effectiveness.

    Failure by academics, politicians, and IT experts to understand the diversity inherent in the health care industry will result in a dash for cash by all those 800 vendors who push their wares through a REC and then fold by Tuesday after selling one system to one poor provider who thought the REC broker they weren’t paying was looking out for their welfare.

  • Assuming that a large group of people are all interested in buying the same EMR, the REC could provide some real benefit to the clinicians. The problem is that the RECs are going out and signing all these contracts with EMR vendors when they haven’t gaged the interest of local clinics about which EMR vendors they’d like to sign up with. Don’t get me wrong. There are A LOT of potential pitfalls with the RECs, but some clinics could save money if the EMR they really want to purchase they get at a nice discount thanks to the RECs.

    Let me clarify my previous statement. I’ve seen EMR implementations result in more efficient AND effective practices. Depends on which EMR they chose and how they implemented it.

  • Great post! In my experience at our company we have a slightly opposing observation when dealing with our clients who are all hospitals.

    (A bit of context about us without trying to plug our firm) We have a steady stream for the past 10 years of hospitals proactively moving from managing their policies by paper, binders, and random shared drives to our PolicyManager system.

    This sheds a slightly different light to the point you make in your fifth paragraph about other industries other than healthcare adopting – “industry specific programs and platforms for each industry. Are they perfect? Of course not, but most are far more efficient than rooms and drawers full of paper records. And there probably isn’t an industry that has made the switch then decided after to ditch the digital and go back to paper.”

    Our direct experience has shown us over a thousand hospitals that have moved to an industry specific system to manage policies. Is our system perfect? No. However our hospitals are constantly helping us to refine it so they can get more ROI out of it. This shows real progress at least at the hospital level, especially as most decision makers we are dealing with have no plans to revert back to manual or paper-based methods that were previously in play.

  • John…

    If there are such a “large number” of persons (practices) … “all interested in buying the same EMR” then maybe that EMR vendor ought to be just stocking the shelves at Staples or Best Buy.

    In my experience and in reading broadly on the EMR/EHR topic the most common critique is that the stock application fits with the diversity of the practice’s business and clinical operations. For one REC to find a large group of providers all with the same business and clinical priorities is not what most have found to exist in reality.

    If I want a ‘vendor neutral’ perspective … I would seek an EHR/EMR expert consultant such as yourself to help us …

    1) Define our business and clinical requirements

    2) Define our hardware and current software capabilities and limitations to support client hosting of an EHR/EMR system

    3) Identify competing vendor products, services, training, and other after market support meeting our priorities

    4) Help us decide which “box” to buy

    5) Work with us as we implement the right system and help us define downline needs and the ongoing relationship with the vendor.

    Implementing an EHR/EMR is an important step for all HCOs and practices to effectively carry out. I believe that can best be accomplished by engaging a consultant (again such as yourself) rather than think I am going to get an effective match from a REC who has no loyalty to provide me anything and is more concerned about meeting governement milestones in order to get paid.

  • DK Berry,
    I agree in their current methodology that it doesn’t make sense. I’m going to do a future post on this, but what if the RECs actually educated the clinics on a good EMR selection process. Then, based on each of the clinics EMR selections, they go and negotiated the EMR vendor pricing. This way they’d be allowing for clinics to do a proper EMR selection and then providing benefits in aggregate based on the independent choices made by these clinics.

  • John … Why do I need the REC to “educate” me and then “negotiate” on my behalf? I’d rather hire a consultant direct and negotiate with the vendor myself.

    How do I know that our practice will “do a proper EMR selection” … if the only vendors being presented are those that the REC has an agreement with?

    I will continue to debate any idea that there is an advantage that a REC can negotiate pricing across many vendors without giving away the specific needs of the HCO/practice.

    As I said before … no way does any REC guy whose performance is not something I get to judge getting between me and an EHR solution which affects top line performance … bottom line profits … and governement defined “meaningful use”.

    If we hire a consultant we can hire and we can fire … and we still get to negotiate our own solution.

  • DK Berry,
    Wait for my post and you’ll see my full thought, but the idea would be that REC’s don’t provide EMR vendors in the “proper EMR selection process” but only work with EMR vendors AFTER the clinics have gone through their own individual selection process. So, each clinic is autonomous, but provided vendor neutral resources to help them make the right selection for their clinic. Then, the REC can just provide resources for the EMR software most of the clinics choose.

    Basically, the clinics drive the process instead of the RECs.

  • Tom –
    I will apologize up front for this lengthy comment and that I am late in leaving a comment. I found your post very interesting but also off the mark in regard to the Healthcare industry and the business side of small medical practices.
    I would first point out the fallacy of your equating the Healthcare industry with medical providers. The healthcare industry is a “monster” that includes everything from your hospital and doctor to insurance companies, pharmaceutical companies, medical equipment companies, and health IT companies, in addition to many others. Obviously, most of these companies have embraced technology to sometimes unimaginable degrees (!), as an example consider all of the information that your health insurance company has collected on you over the years. So there is really nothing different between the Healthcare industry and any other business in regard to its acceptance and adaptation of advancing technology. The main issue that is now occurring is in regard to the mandated effort to get medical providers to adopt and fully implement electronic medical records in a relatively very short time span.
    Let me note for the record that I am a firm believer in electronic medical records and do not believe that medical providers are intent on believing that the paper-based system of record keeping is superior or the best method. I think a lot of the problem that accounts for the resistance is related to the environment in which medical providers (this includes doctors and hospitals) are forced to practice and the real world finances of medical providers.
    While it may be acceptable in other businesses to take on new technology, even though it may not be perfect, because of its improved efficiencies and other benefits. In medical practice, the current societal and legal standards do not accept anything less than perfect. While credit card companies and other businesses can get away with a data breach, this cannot occur in a medical practice and will result in severe punitive fines, if not lawsuits, under rules such as HIPPA. Unfortunately, the current electronic health record systems do not come with a “absolute guarantee” against these kinds of breaches so providers are the ones who are ultimately responsible.
    In regard to the real world finances of medical providers, there is a very significant difference between the healthcare industry in regard to medical providers and just about every other business. Specifically, medical providers are the only businesses that I am aware of in which the price that is paid for the product or service is not determined by the person rendering the product or service. While this topic leads to a far more involved discussion, I put it out there so that you understand that the cost of an EHR is not something that the medical practice “business” can just pass through to its “customers” by raising the prices. In addition, the payments that medical practice “businesses” have been receiving over the years have been essentially stagnant or going down. This difference makes the move to EHRs a very costly endeavor which can only be made up for by seeing more “customers”/patients. While maximizing the utilization of all of the EMR benefits has the potential to increase revenue by improving efficiencies, the time that a provider needs to spend training, transitioning, and streamlining this process only takes more time away from him seeing patients, and therefore seeing less, not more “customers”.
    I believe that this is probably one of the biggest issues that produce resistance to EMRs.
    In regard to the funding and other resources that have been made available to medical practices and hospitals, the potential amount of money that is available per provider is less than 50% of the actual cost of an EHR system, as per the government’s own estimates. While up to $44,000 is available through Medicare, the government actually estimates the cost of an EHR per provider to be $104,000 – $54,000 in capital costs and $10,000 per year for maintenance and training (per the Federal Register). For a small practice, this represents a very significant investment.
    And in regard to the RECs, they have already received significant funding from the government, so they have already been paid and have their money. But I would point out that the medical practices are still the ones left to pay the bill for the EHR, and if the REC does a poor job in helping them select a system and it doesn’t work for the practice, then it is still the medical practice that is stuck with the bill and has to go out again to find and pay for another EHR system.
    I feel that these are some of the significant reasons for the resistance to EHR adaptation because they do represent different business models that the adaptation of the technology alone still does not solve.

  • Frank MD,
    I agree, I should not have used “Healthcare Industry” as it certainly is too broad of a term for the topic. I also agree that the “business” side is far different than other industries as well, particularly your point about who sets the price, who pays, etc.

    However, I am confident there is a way to create a system where there is more exchange of information when it comes to medical records (perhaps that’s the eternal optimist in me!) While it is only part of the proposed Meaningful Use, it’s the one that will strike the biggest chord with the patient/consumer/customer, as we have all grown accustomed to having access to information. Perhaps the issue right now comes down to the fact that we aren’t looking at a phased implementation where things are done in steps, but a giant leap where everything must be done at once.

    Of course there are numerous legal issues surrounding breaches, but I don’t believe there will ever be a “guarantee” that any digital information is 100% secure. Done correctly, it can be very close, but there is always a risk. However, there is also risk in the current paper records as well. Faxing records from one office to another runs the risk of dialing a wrong number or the wrong person seeing the information on the receiving end. Multiple parties have access to private patient information, from transcriptionists to the people in the insurance company mailroom. Unfortunately, there is always an eliment of risk when it comes to the exchange of information.

    In addition, the penalties for breaches in other industries can be just as severe. While the information may not be as personal in nature as a persons medical records, the result of a breach of information related to finanicial or legal records can carry enormous financial consequences to the company at fault.

    I appreciate your comments, and you also have a new reader for your blog. Reading about this on a regular basis from someone who actually uses these tools I think is extremely valuable for anyone on my side of things. The only way this whole thing will work is if everyone keeps conversing and learning, and perhaps we’ll be able to reach a middle ground that ultimately provides patients with the best possible care, while not having an adverse impact on the actual provider of that care in the process.

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