Looking at Slow EMR Adoption

There’s been a whole lot of discussion going on in this post on EMR and HIPAA called Why EMR Efforts Are Proceeding Slowly. The comments are an interesting read for those interested in EMR adoption. However, Jack Callahan, Executive Vice President at SRSsoft, emailed me a very passionate response to that post. I couldn’t let a passionate response like that go relatively unseen in my email inbox, so here’s his response (published with permission):

A major reason why the rate of EMR adoption is so slow is that, despite vendor claims, the actual needs and priorities of the busy, practicing provider are not built in. I’ve worked closely with three EMR companies, and am aware of more than three hundred EMR products, almost all of which, like lemmings, have decided to follow the old CCHIT design-and-development pathway over the cliff. For them, the basic design criterion involves answering the question: “How can our EMR product more effectively generate an automatic Progress Note so the doctor doesn’t have to dictate it, thereby generating cost savings to pay for the EMR?”The answer to that question always seems to be: “Enter a boatload of data from each exam.” Since most of this is entered by the provider him or herself, this is very impractical, especially for busy providers with limited panels to see patients due to surgical or other procedures that generate their primary revenue. The current products pursuing certification have enormous amounts of irrelevant functionality, require way too much data entry, and are largely unusable, especially by specialists and surgeons.

To make an analogy, the current requirements and “certification” process basically dictate that an EMR should be like this:

It should have wings so it can fly, but be shaped like a dump truck because it has to carry a lot of data. It needs to have a half-track undercarriage to provide good traction, no matter the terrain, but it must also function like a submarine in case it ends up in water; further, it must be made totally of recycled, renewable-resource materials for environmental concerns. It must be able to dig deep holes, but also be able to hover; it must be capable of high speeds, but also of changing direction easily. Of course, it should seamlessly switch from any of these modes of operation to any other mode on the fly and without unreasonable delay. Further, it must be adaptable enough to be modified to whatever purpose each user wants, but without giving up a single one of the attributes above, just in case.

Providers must purchase the product with their own funds . . . but may qualify for ARRA reimbursements if they meet certain requirements. These requirements will not be clearly spelled out in advance, however, but will become increasing complex over the five-year reimbursement period, which will end up covering only a small portion of the cost of the product. To qualify for reimbursement, providers must show “Meaningful Use” of the product in their practice—i.e., they must show they can hover, dig holes, navigate underwater, cross a swamp, carry twelve tons of cargo, fly from point A to point B, and spit wooden nickels if requested . . . all without making any mistakes. These requirements will remain in effect even if the practice only needs a simple product that goes in circles around a track.

Any vendor will be allowed to produce these products, but all products will be subject to “certification” that proves they can do all of the above, and more. Every vendor’s product must to be able to exchange parts with every other vendor’s product . . . and with any government-designated agency as well; however, the parts to be exchanged are not specified at the time the product is made. There is no standard for how complex these devices will be to operate . . . vendors will differentiate their offerings by hiring trained users to demo for providers how easy to use their product is by performing “canned,” simple maneuvers that they have spent months, or years, demoing in the past. Vendors can also “guarantee” they have passed “certification” to providers, who may assume that this means that Meaningful Use is also guaranteed; however, vendors have no accountability for Meaningful Use, only for certification. That chicken will come home to roost in 2011.

Some providers see this conundrum more clearly than others. Those are the ones resisting the enthusiastic adoption of EMRs for reasons of incentives alone. But with the marketing and PR weight of more than three hundred vendors seeking certification, with $36 billion in incentives dangling from the government Giving Tree, with the threat of potential penalties for not buying one of the monstrosities above by 2015, and with the offices of ONC and HHS pushing for adoption under administration pressure, how many bad decisions are going to be made in the coming year?

Providers will do best to not use the ARRA incentives as a criterion for adopting an EMR. They should buy an EMR because it makes sense to improve their practice . . . and they should find one that truly fits the way they practice medicine. Meaningful Use should not mean hours of entering data into a menu-driven system. Converting from paper to electronic records provides probably 70% of the benefit of adopting the right EMR, and every single practice will benefit greatly from that alone. Anything else is gravy. And there is lots of gravy to be had, with the right choice. Unfortunately, a bad choice can leave you with a very expensive, unusable, “certified” monstrosity. There are lots of them already lining the roads along the EMR highway, especially where specialists are. And there will be many more starting in 2011 if practices don’t do their homework.

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.


  • Thanks for the great post, John. I’m going to redirect my clients to this post. They will appreciate it.

  • John,

    Great post!

    If you think the “meaningful-use” criteria list is “over-engineered” what would be the top 5 or 6 features that are a must on an EMR (including the “electronic records” instead of “paper” part) and that would cover say 80% of the physician basic requirements – from your point of view? Is there an 80-20% rule where 20% of the features being used by 80% of the doctors productively and that would yield bulk of the benefits?

    Would it be reasonable to say such a list would consist of the following?
    a) CPOE,
    b) electronic prescribing,
    c) electronic lab results,
    d) electronic patient demographics / lists / notes,
    e) electronic claims / eligibility and
    f) standard patient data exchange (say using CCD)

    I am sure there is some rationale behind the (long) list of meaningful-use criteria list but I have not seen anything that justifies this list comprehensively.


  • nsiva,
    Stop thinking so rationally. This is government work and so we have to through all common sense out the window.

    I think the 80/20 rule is interesting. I’ll have to think about it more.

    The challenge that I think HHS/ONC face is that they are bound by the legislation they’re given. So, they have certain requirements that they have to meet. I’m not sure exactly how flexible that is.

  • Great post, I really enjoyed it and feel that it is right on the mark. Unfortunately, as Mr. Callahan points out, the current system for EMR software development is actually incentivized to produce these gigantic monstrosities. The fact that the current federal government program essentially “forces” providers to adopt one of these monsters, in order to qualify for a benefit, only perpetuates this current system. Hopefully, someday, common sense will enter this equation and lead to the creation of EMR systems that seamlessly integrate into the medical practice.

  • Really interesting and thoughtful piece. Usability is so key to these systems. Cost is the first hurdle, then they productivity lag and keyboard. Beyond data capture, after we get these EHR systems in, we’ll need to figure out how to get meaningful data out. Looking forward to continued innovation in Clinical Language Understanding.

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