So today the New York Times ran a story about WalMart’s foray into electronic health records. According to WalMart, they are going to bundle a Dell laptop, software, installation and maintenance for $25,000 and sell this package in WalMart stores. This tells me they don’t know ONE SINGLE THING about what is stopping physicians from using EHRs, or one thing about how physicians regard themselves (as professionals).

WalMart thinks because it was successful with the consumer play of $4.00 prescriptions that it can also be successful on the provider side. Let me just say that, having evaluated pretty much all the leading products, the software they chose isn’t one of them, and that’s only the beginning of the problem.

Here’s a quote from a doctor friend of mine who uses EHRs and even wrote one for himself. He’s not only a D.O. but also a MS in Medical Informatics. I sent him the Times story.

“You gotta love that. But $25K for a solo doc? Come on now, I figure Walmart should be selling it for $29.99 or something. Then I could pick up an EMR or 2 at the same time I get some new underwear. I really did laugh when I read that. Talk about everyone wanting a piece of the pie. What’s next, primary care at the Taco Bell check out counter? I’ll have a side of Lipitor with my grande burrito and please send the script to my pharmacy benefits manager at the Circle-K. He’ll check if it’s medically necessary after he gets done filling up the coffee and putting on some more hot dogs. I guess nothing should surprise me anymore.”

Maybe we should ask whether EHRs even solve the problem of rising medical costs and productivity in medical offices before we begin offering a “total solution” at a cut rate price.

A sales rep from Allscripts has sent around the following information about what the stimulus plan will do to incentivize the deployment of electronic health records.  I’ve long been of the opinion that they will only happen if the Center for Medicare and Medicaid Services (CMS) mandates them. That’s what happened with electronic claims processing. So here’s what has happened:

“In addition to its other components focused on economic stimulus, the law provides $20 billion in health information technology funding.  The total includes $2 billion in discretionary funds and $18 billion for investments and incentives through Medicare and Medicaid to ensure widespread adoption and use of interoperable healthcare IT systems such as the Electronic Health Record.  Physicians who have not adopted certified Electronic Health Record systems by 2014 will have their Medicare reimbursements reduced by up to 3 percent beginning in 2015.

“With the stimulus, the Centers for Medicare and Medicaid Services (CMS) will pay physicians between $44,000 and $64,000 over five years, beginning in 2011, for deploying and using a certified Electronic Health Record to care for patients.  The stimulus package is expected to ignite significant job growth in the information technology sector and, according to a Congressional Budget Office review of the legislation’s impact, drive up to 90 percent of US physicians to adopt Electronic Health Records in the next decade.

“Once a provider starts collecting incentive payments for meaningful use of an EHR (whether in 2011 or beyond), he or she can continue to collect PQRI payments but cannot continue to collect ePrescribing payments.

Under the Medicaid incentives, nurse practitioners and nurse mid-wives are eligible for incentive payments if they demonstrate meaningful use and meet the minimum threshold required of the Medicaid incentives. Under the Medicare incentives, the payments are not available to mid-levels; they are available only to MDs, dentists, podiatrists, optometrists and chiropractors.”

There have been a lot of conversations on Health Care IT topics; specifically, Electronic Medical Records and related things, recently the conversation has come to a number of places that have caught my attention. These sites have perspectives that I find interesting, some have been directly involved with Health Care IT, some less so, all of us as patients/consumers.

Francine Hardaway has some experience and interesting things to say in a number of posts, over at Huffington Post Are EMR really the answer? and , talking here about how President Obama has Health Care IT on the radar, and her personal experience. More recently, she talks about how it can be done wrong. I generally tend to agree with Francine, but bring some slightly different experiences to bear.
Of course I had things to say in the comments of each post, and these together make up a more complete picture of my view of the challenge, some ways to do it, and ways to not do it. I’m consolidating them as there was a lot of overlap. I don’t believe that I have unrealistic desires, I want things to work for all of us.

• As a patient/consumer, I really want to be able to take a CD from my current Dr, hand it off to a new Dr, and not get looked at as if I had 3 heads.
• As a technologist, I want the data to live in a way that is clear, concise, and portable.
• As a citizen and worker in the US, I want this country to again have a leadership role in thought and practice of Health-care Delivery

There are a few things that seem to be obvious to me.

• We aren’t doing much right in how we communicate. Really, have you had a conversation with the insurance specialist at your Dr’s office lately? It’s like they are speaking Klingon.
• We _must_ have standards, that’s one of the few things that we can largely agree on. We don’t have to agree with every last detail of those standards, we just have to know that standards are how we come together to better deliver the goods.
• The current model of Health-care Delivery is unsustainable

There are so many opportunities to improve, but let’s focus on one area here, information management.
There are so many things that _can_ be done, by so many, fed, state, individual, AMA, all the way down to individuals. I advocate one thing from the federal government as a first step. Standards! I believe that standards that promote interoperability are a significant part of all of these things.
There is a lot of room for debate about what the role of the Federal Government is, but I don’t think that many would argue that leading the charge for standards in operation and interoperability isn’t something that government can’t do, in fact I would argue that government is uniquely positioned to do just that, lead. I see standards as key, and Fed Govt as the one to manage standards, then once in place bring providers to them with both carrots and sticks. By making the large, (VA, Medicare/Medicaid), government agencies use them, then take all opportunities to apply leverage to business and standards bodies to adopt those standards if they wish do do business with those agencies they must work with those standards. We can jump start the adoption of these standards. I think that there’s a real chance to create jobs, and open up the market some. We can not only deliver better service to the consumer and reduce mistakes, but we can save money too!
How standards are implemented in software is the part that conflicts with corporations maximizing profit. Corporations have a single motivation, earn large profits. The software business is somewhat unique in that the first copy of software is very expensive to create, all other copies are nearly free, just media shipping and sales.
There are some islands of standards, PACS and RIS are such systems, I worked for a hospital in the mid 90′s we had PACS then, surely it’s been around long enough that we should have stable standards in place. In fact I’m sure that in the PACS arena it is stable, but what about getting things out of that island? The things that I have seen done to get different systems to communicate are reminiscent of “tin cans and strings” mechanisms. Interoperability in the medical software field has never been great, I think that’s one of the key problems with adoption. Clearly there are other important reasons, but I think that the ability to achieve relatively straight forward interoperability will help make these others lower barriers.

It’s been a while, over 10 years, now since I worked at a hospital, now its a bank where I earn a living, many things are eerily similar. Craplications abound, there are a few categories of these things that cost a relative fortune, but are worth just a tiny fraction of that if anything at all.

There are small standalone niche products, they tend to get bought and forgotten about for many years, until it completely fails and there is no company to be found to support it, and the people who implemented it are long since gone. The only people around who know anything about it only know how to prop it up, and the cost to replace these products is prohibitevly high

There are a small number of really large providers of software, that provide solutions to the vast majority of hospitals. These are ripe for standards compliance moves.

Then there’s the kind of thing that Francine is talking about in one post, the GE product is just one example. This is rampant in large scale software from large companies. Really big companies like GE don’t make software, they go out and find components and bind them together with bubble gum and bailing wire. There’s actually an advantages to this strategy, (well, if you are the seller it’s an advantage)

• There’s nobody on the planet that understands the whole thing enough to support it.
• There’s nobody on the planet that understands the whole thing enough to replace it.
• There’s really good money to be made in services installing, maintaining and upgrading it
• Once the fish, er customer, is hooked it’s nearly impossible to move off of this platform

Quite often the support models of large packages call for annual contracts to pay for the support of the very product that you just paid millions for. It is not uncommon for the annual support contract to be 10% of the cost of the software. Then if you want to make significant any changes to the configuration of the product it is further consulting time, charged by the hour, frequently at rates over $200 per hour, plus hotel and other travel costs.

By moving to standards based inter-communications we have a chance to flatten some of those speed bumps. Independent certifications and training would enable more people to become fluent in the tools and procedures to bring suites of applications together into a EMR system. By having well defined standards we will be able to have single repositories for a person’s health records, and all of a hospital’s applications can leverage that. Imagine your health record as the hub of all of the communications, all departments, and external entities managing the parts of that record that they have valid data for.

There is a very interesting podcast, Data Finds Data it took more than one listen to this for me to feel like I had gotten the all points out of it that I would, it’s worth a listen.

But, of course I’m an IT type, that’s my perspective.

I’m beginning to think we need to stop Obama from implementing electronic health records. I didn’t always feel this way.

I’m sitting in a meeting with a doctor friend of mine who is now working for a clinic that uses GE Centricity.This man, a D.O. with a master’s degree in medical informatics, is telling horror stories about how an entire state’s health care system is trying to run on an electronic health record that no one can use.

They are using it because they bought it, although the doctor who bought the system said it bankrupted him and forced hin to sell his practice to the hospital. The hospital doesn’t even use Centricity, it uses Cerner. There’s a jerry-rigged interface to make Cerner talk to Centricity. The databases are not shared.

These are the two leading EHR products on the market right now. But NextGen and Allscripts are no better; I’ve evaluated them all, and I know. Before we implement EHRs, there had better be a panel of users (physicians) talking to Obama, rather than a panel of software companies.

This same doctor, and another friend of mine and I started a small non-profit a few years ago to evaluate these systems and help small practices implement them. The other friend is an MIT grad who has been a professor of Medical Informatics. I was their marketing front end. After helping one practice implement a system, we dropped out of the field. We realized that health care IT doesn’t help the doctors as it is now deployed; instead, it kills their productivity and hurts them. When they don’t adopt it, we criticize them, but THEY ARE RIGHT!!!

A few big products control the movement for CCHIT certification, which keeps smaller, perhaps more useful products out of the market. To get your product certified by CCHIT costs a $30,000 application fee, and then a couple of hundred grand more to go through the process.

This doctor has written his own EHR, so he knows how they work. He gave up marketing it because he was such a small fish in a big pond.

He says GE doesn’t want you to be able to do anything, so they can service the doctors who buy the system. He says GE’s database is sloppy to the point of of absurdity. GE acquired the database from another company, and rather than fix it, they just layered things on top of it. Key fields are named differently even though the data is supposed to relate to each other. And the rich text markup is stored with the data. It’s unreadable.

It’s this doctor’s opinion that no one understands this product. GE’s documentation is also difficult to use. These are expensive, IT-controlled products that are productivity and efficiency killers. You can’t even see the data in the software the way that you want.

Before we force the doctors to make health care worse with these existing products, let’s examine what we are doing. From a usability perspective, the software just isn’t there.