News 1/21/10

If you are a practice management vendor without a complimentary EHR solution, chances are you are looking a mate (or two or three.) LeonardoMD finds a new partner in MedAppz and will now offer the iSuite solution to its client base.

Alternatively, vendors already entrenched in the PM space are looking to create EHR functionality themselves. This appears to be the case for Medrium, who just announced a number of enhancements to its existing “complete practice management” offering. The company says it will roll out an EHR the first half of the year and claims it will allow physicians to meet all meaningful use objectives. Medrium is also adding a document management feature, patient eligibility checks and PQRI performance options.

This Miami start-up provider of web-based physician practice software raises $2.3 million from unnamed investors. CareCloud plans to use the new money for … developing an EHR product!

Sunquest introduces a new physician portal that will allow providers to integrate patient lab results and enhance integration with EHRs. The Sunquest Integrated Clinical Environment has been marketed in the UK and other countries for the last 10 years.

CCHIT updates its 2011 certification requirements to reflect the latest changes in the interim final rules. For vendors who have already qualified for 2011 CCHIT certification, CCHIT will offer incremental testing at no charge.

Doctors in Ohio are likely to oppose proposed legislation requiring them to consult a statewide database before prescribing narcotics. The Ohio Medical Society believes the requirement would be an administrative burden for providers, especially at a time when many are trying to implement EMRs. The state sheriffs’ organization and others think such a law would reduce pill shopping, the illegal sale of prescription medications, and drug overdoses.

AdvancedMD adds Steven ZoBell to its executive team, naming him chief product and technology officer. He was previously CTO for inContact and involved in the interactive game world, overseeing development of several Microsoft franchises like Amped snowboarding, Top Spin tennis, and Links golf. It might be fun if he incorporated some of his gaming expertise into AdvancedMD’s EHR product.

A few short weeks after releasing the latest interim rules, some members of the HIT Policy Committee are now saying CMS should not have removed the requirement for physicians to generate progress notes for each patient visit. The opposing members say that without this element, providers miss an opportunity to create useful information and improve quality reporting. Members also believe CMS should not have removed the requirement to document advanced directives for the elderly and to develop easy to understand patient information resources.

The reports and images from Haiti are horrific. I’m thankful for the efforts of our US medical teams, including Dr. Jonathan Crocker, who provides a personal update here. Administrators at BIDMC are regularly adding new updates from their doctors who are giving a hand in Haiti.

iMedicor partners with Direct Medical Solutions for marketing and sales assistance. DMS sales reps will pitch the iMedicor portal to physician practices, as well as hospitals and HIEs.

Sometime Wednesday morning, HIStalk Practice’s 100,000th visitor stopped by. As you can see, I tried to document the occasion, but missed the magic moment by seconds. Thanks to Visitor Number 100,000, whoever you are, as well as you other 99,999 readers who have visited over the last year or so. We’re currently on track to have our best month ever and I’d be ecstatic if we hit 200K sometime in the fall.

Tomorrow we run the sixth and final segment of our EMR Vendor Executive series on Meaningful Use and Certification Requirements. The question: which criteria do you expect to be changed after the comment period?  Mr. H and I have received positive feedback about the series and hope to run similar ones in the future. If you have a burning topic you’d like to propose, let me know.

E-mail Inga.

Intelligent Healthcare Information Integration 1/20/10

Blowin’ in the Wind

I know it’s not just me. If you’ve read through the recent series “EMR Vendor Executives on Meaningful Use and Certification Requirements” here on HIStalk Practice, you know not everyone agrees that the “Meaningful Use” criteria (MUC) are all roses and rainbows.

Still, it feels as if the voices which ring most true to my trench-weary ears are not the ones being heard most loudly nor echoed most frequently. Most of the big brains of the industry, be they governmental guiders or corporate cognoscenti, seem to be enraptured with the power and the glory of the MUC. Me? I’m feeling more mired in it.

Don’t get me wrong: I wanna believe, believe me. I want to feel that my medical cohorts here in the trenches really can absorb the MUC, all 700 pages or so. I want to have faith that my fellow EPs (Eligible Professionals) have more time in a day than do I in order for them to adjust all of their long-ingrained work habits and processes while still seeing all the folks who need care. I want to have the confident sleep of the assured who know that meeting regulatory demands won’t hinder their ability to meet next week’s payroll, shortchange their doctor-patient face time, nor further diminish their familial familiarity. (Remember me, son?)

I also want to believe that the big brains in the big places have the best interest of all of us at heart. I know most of them come from bigger centers, have bigger educations, and often have bigger bank accounts than many of us middle America minor leaguers. I want to believe that we matter to them and that they understand that the majority of healthcare in the U.S. is provided by smaller players who have no I.T. team, who have techno-illiterati-filled staffs, and who really want to focus on doing what’s right for our patients, not our data centers.

People like Evan Steele of SRSsoft brighten my outlook, but not because he is an exquisitely optimistic and rosy-glassed opinionator. Rather, his bold honesty and willingness to sound un-salesperson-y are what make him one of my current mini-heroes. He expresses an understanding of the enormous workflow issues entailed within the MUC. His forthright skepticism about the abilities of me and my trenchmates to be able to shovel sufficient MUC to be able to keep our heads above it are spot on, at least from the view down here. (See his comments in Part 2 and Part 3 of the series.) Evan has been particularly impressive in his understanding of us grunts … a tip of my MUC-covered helmet to you, sir.

For now, though, I watch and listen. The breezes seem to be bringing sounds of big institutional choirs and big center songs with very few micro-doc choruses. I try to raise my voice, but the MUC seems to be a bit thick down here.

From the trenches…

“The men with the muck-rake are often indispensable to the well-being of society, but only if they know when to stop raking the muck.” – Teddy Roosevelt

Dr. Gregg Alexander is a grunt-in-the-trenches pediatrician and geek. His personal manifesto home page…er..blog…yeh, that’s it, his blog – and he – can be reached throughhttp://madisonpediatric.com or doc@madisonpediatric.com.

EMR Vendor Executives on Meaningful Use and Certification Requirements – Part Five of a Series

We asked several vendors a series of six questions related the federal government’s recent announcement on the latest proposed meaningful use definitions and EHR certification criteria.

Practices are required to provide patients with electronic copies of their visit information. How will providers do that and how will patients use that information?

Allscripts – Glen Tullman, CEO

As the Interim Final Rule (IFR) and the Notice of Proposed Rule Making (NPRM) both describe, there are many ways for physician practices to provide patients with clinical summaries of their visit information in paper or electronic form.  Many of our clients have already selected the Allscripts Patient Portal as the best means of delivering this sort of secure health information to patients, whether it’s a visit summary, test results or an email message from their physician.   We expect that more healthcare organizations will turn to patient portals to satisfy this requirement.

Patients, for their part, are likely to use the information they obtain from a portal for self-education, which tends to improve compliance with their physicians’ prescribed therapy. We also hope patients will share the information they take away from physician visits with other providers they may see.  That is exactly the sort of information exchange that can improve the coordination of patient care across all settings, improving overall quality and lowering costs from such things as duplicative tests.

To that end, we suggest that HHS require providers to include patient portal functionality within the EHR they implement in order to meet Meaningful Use criteria.  Personal Health Record utilization is not  widespread at this point, but enabling physicians to be change agents in notifying patients of the availability of critical health information is an approach we strongly support and which we believe would quickly increase the number of PHR participants. We also suggest that HHS require all EHRs to include access to at least one Personal Health Record and one or more storage mediums, for example, Microsoft HealthVault or Google Health.

eClinical Works – Girish Kumar Navani, CEO and co-founder

There are currently tools available that will make that a possibility with little effort. As it stands now, providers using eClinicalWorks can have the visit summary automatically uploaded to the eClinicalWorks Patient Portal. Once there, all a patient needs is a username and password to obtain that information. Having an informed patient will increase the probability that key aspects of the visit will be remembered and followed-up on, if need be, while at the same time reducing calls into the office.

Eclipsys – Philip M. Pead, President and CEO

I believe this component of the criteria will increase the deployment of patient portals, although the easiest way to meet this requirement in Stage 1 would be a simple encrypted file copy of the information to a CD-ROM or USB-Memory device.

e-MDs – Michael Stearns, President and CEO

Our providers have this capability currently as they can export some or all of the information in an electronic format that can be provided to the patient in a number of formats, including a patient portal.  Patients and family members can make use of this information by sending it electronically or physically carrying it (e.g., on a USB key) and making it available to health care settings that do not have access to an interoperable EHR.

We believe this functionality will gain increasing importance as providers and patients become more involved in care coordination, in particular in the setting of chronic disease.

GE Healthcare – Vishal Wanchoo, President and CEO, GE Healthcare IT

The meaningful use criteria specify a wide range of electronic ways that this can be met, for example PHRs, patient portals, CDs, and “thumb drives.”  We expect providers will use methods that meet patient needs and are consistent with their technology.  Likewise, patients will use this information to meet their needs, such as reviewing information at home, giving it to another provider, or using a PHR.

InteGreat, a MED3OOO Company – Tom Skelton, President

This can be accomplished by a simple print of a patient’s health summary and completed note. In addition, this can be accomplished by having an integrated patient portal with your EHR. There is also mention that the format given to the patient must be “readable and understandable”.  We think some additional guidance here would be beneficial. Since certification under CCHIT 2008 and beyond requires support of the HL7 CCD, we expect that most EHR products will provide the visit information via a secure web portal that is populated via a CCD.  Some practices may prefer to provide the electronic copy on a CD or memory stick. We suspect that the format will still be the CCD so that the data can be viewed using a standard web browser. Either way, patients will use it to research their medical conditions on the internet and to bring their records with them when seeing a specialist.

McKesson – Dave Henriksen, SVP and GM, Physician Practice Solutions

The criteria states that the eligible provider must provide clinical summaries for patients for each office visit in paper or electronic form that includes – at a minimum – diagnostic test results, medication list, medication allergy list, procedures, problem list and immunizations. We offer a robust patient portal that provides patients with online access to that information, but which also makes this information available in other acceptable formats. We believe this approach aligns with the government’s ultimate goal — that patients have easy access to their most current health information so they can make informed care decisions and ultimately better manage their health. For McKesson, we believe that we are well-positioned with RelayHeath’s PHR and HIE capabilities to provide the needed interoperability services to our customers.

NextGen Healthcare – Scott Decker, President

Physicians have always had the capability to provide patients with copies of their automated record. We have been working with our clients to provide this information for several years, however the real challenge will be getting all physicians to meet this requirement, as many don’t do it today. There are also some privacy and security issues to be worked out before record sharing can be done as effectively as the authors of these regulations wish. We hope that patients will also use their personal health information to strengthen their commitment to better health by working more closely with their doctor.  Educating patients on the benefits that personal health records can have on their health will be key.

Sage – Lindy Benton, Chief Operating Officer

Our solution today is to enable the patient to access the clinical record on-demand and online though our practice portal. This enables consumers to use that information in whatever way they feel is appropriate. Patients can view or print the clinical summary from the portal, or merge the CCD into their PHR.

Alternately, the practice can provide an electronic copy on a memory stick or CD, however, this leads to the second part of this question—how will the patient use it? So the online portal seems to us the most beneficial way to share clinical information with the patient, in that it is secure, portable and immediately useful.

Ultimately, we are interested in putting the patient in a position to leverage emerging technologies. We are of the opinion that ubiquitous platforms will emerge, such as a healthcare-geared Facebook-type platform that patients will gravitate toward. In this case, it becomes a question of secure messaging and allowing the patient to consent and direct their record accordingly.

SRSsoft – Evan Steele, CEO

We don’t see this as a measure to save healthcare costs or provide improved care. This is a privacy/security/access issue; a convenience for patients who need to have access to the data in their records for some reason. I cannot envision the majority of patients requesting their medical records on a CD or a thumb drive, now or in the foreseeable future. Patients may need to request copies of their records, or portions of their records if they relocate, change providers, etc., but they typically want paper documents that they can read themselves and share as they see fit. Many providers have issues with this in that they must be much more careful and perhaps less candid about comments and notes they make in patient records if they know the patient is going to view them. Some comments could alarm them or be cause for other concerns if providers are just noting things to look out for in the future, for example.

You do not need a comprehensive, point-and-click EHR to make records available to patients. In fact, it is a lot easier to and faster to do this with a hybrid EMR. In addition, most physicians find the templated exam notes that are generated from a point-and-click EHR to be of little value—difficult to find information and lacking the detail, nuance, and precision that most specialists require.

News 1/19/10

From: Certifiably Confused “Re: EHR certification. A vendor is suggesting its product is ‘meaningful use certified,’ which will permit its physician clients to qualify for ARRA money. Is ‘meaningful use certified’ an official designation? And what does it mean?” I had to consult with Evan Steele of SRS, who has become a certification guru of sorts. No, I don’t believe that ‘meaningful use certified’ is an official term. More likely the vendor is suggesting his solution will meet the certification requirements under the new HHS-certification regulations. Evan believes that CCHIT will be one of the certification organizations but that full (comprehensive) CCHIT certification will not be necessary for an EHR to qualify under ARRA. Look for the ONC to release another proposed rule regarding the certification process and the authorization of certification organizations. In my opinion, the clarification can’t come soon enough.

Girish Kumar Navani of eClinicalWorks wins a 2010 Business Leader of the year award, presented by Worcester Business Journal. The newspaper includes an interesting profile on Navani, who won in the Big Business Leader category. Navani provides some history on the company, which is now in its 10th year. My favorite comment comes from the Micky Tripathi, CEO of the Massachusetts eHealth Collaborative. Tripathi calls Navani “an unbelievable salesman.” I love sales types, and I agree with the assessment.

If you are looking for an EMR to work with your iPhone, MobiHealthNews provides a list of 12 applications with iPhone capabilities. By this time next year, I bet we’ll have more EMRs with iPhone apps than without.

Allscripts CEO Glen Tullman is quoted as saying his company will hire another 250 people in coming months in sales, training and solutions management. Tullman also says the company’s workforce grew 10% last year, to about 2,500.

HIE provider Medicity announces a 91% increase in bookings in 2009 versus 2008 and a 35% increase in its five-year revenue backlog.

Advanced Foot and Ankle Specialists (FL) goes live with Aprima Medical Software for EHR and PM. Doctor’s Administrative Solutions provided the training and remote hosting services.

Two community health centers are partnering with Cisco, the HMO Molina Healthcare, and the state of California to establish a $10 million telehealth pilot project to provide health services to underserved communities. More than 15  sites will be connected over the next six months.

eClinicalWorks signs a big order with Summa Physicians (OH) to provide EMR for its 223 physicians. Summa Health Systems is already an eCW client, having contracted with eCW in 2006 to provide EMR and PM solutions for its community physicians.

Tomorrow’s question in part five our EMR Executive Series on Meaningful Use and Certification Requirements: Was there enough emphasis on clinical decision support and interoperability?

NoMoreClipboard announces a new patient portal that allows patients to create their own PHR and share clinical and financial information with their providers.

Technology is making “participatory medicine” an easier alternative for providers. Proponents of involving patients more into their own care process believe it can increase patient satisfaction, save time, reduce costs and improve care. Other benefits for physicians: reduced liability risks and possibly a new revenue stream for online consults. It’s all about getting doctors to use the tools, such as email, PHRs, patient portals, home monitoring devices, and social networking sites.

An Ohio woman tampers with her own medical records to make friends and co-workers believe she has breast cancer. She apparently used a computer to cut and paste her doctor’s signature from a legitimate medical record and then added it to a fake one that indicated she was being treated for cancer. Her concerned co-workers raised $7,000 to help offset medical bills, though she actually resisted the help. Eventually the doctor learned about the false documents and notified police. She’s now been charged with two counts of felony forgery. Her motive was unclear though her family says its not the first time she has faked a cancer diagnosis. By the way, I think I have tennis elbow in case anyone wants to send money my way.

E-mail Inga.

EMR Vendor Executives on Meaningful Use and Certification Requirements – Part Four of a Series

We asked several vendors a series of six questions related the federal government’s recent announcement on the latest proposed meaningful use definitions and EHR certification criteria.

Was there enough emphasis on clinical decision support and interoperability?

Allscripts – Glen Tullman, CEO

Yes and no.  While we’re grateful that HHS responded to our request that they push the industry forward with tougher requirements around Clinical Decision Support and interoperability, we would have preferred a much more aggressive approach on both fronts. If not for this year, then HHS should have made it clearer that in 2013 the bar will be substantially higher so we can begin to plan and develop necessary changes to our applications today.  The American taxpayer is investing billions of dollars in this program and they deserve much more rapid progress on Clinical Decision Support (which translates into improved quality) and interoperability (which leads to better quality and lower costs). For instance, HHS could require vendors to support more of the IHE profiles that the vendor community consistently demonstrates are valuable, tested methods of sharing health data in a standard way.

Allscripts has devoted considerable resources to interoperability over the years, as demonstrated by our repeated participation in the HIMSS interoperability showcase and other similar events. Through our leadership, we’ve helped to create an infrastructure of collaboration and connectivity, and we invite some of the other vendors who have not taken part in this effort to join us.

Concerning interoperability, there are a few things we would like to see adjusted in the final rules. We would like to see additional clarity around medication allergies, as well as a stricter approach to problem lists (by allowing only SNOMED CT and not ICD-9).  We expect that both of these limitations will be addressed by the time the 2013 certification requirements are released.  For the Stimulus incentives to have their intended effect, it’s critical to establish true interoperability of Electronic Health Records.

On Clinical Decision Support, we are excited to be part of initiatives that will push CDS and quality measures into the interoperability conversation. We have actively participated with the National Quality Forum, the National Committee for Quality Assurance, the American Medical Association, HL7 and the HIMSS EHR Association in the creation of a new HL7 standard for the expression of Quality Measures.  The new Health Quality Measures Format (HQMF) that these groups have jointly developed will make quality measures interoperable. Right now hundreds of EHR vendors are reading 90 quality measures and trying to extract the logic of those measures from pdf documents.  This is an enormous, clumsy and unnecessary effort. With the adoption of HQMF (which we hope will be part of the 2013 certification requirements) our Electronic Health Records will be able to “consume” quality measures automatically, enabling Clinical Decision Support without the “hand coding” that is so often required today. This will significantly enhance our ability to quickly respond to changes in clinical guidelines, and ensure that our clients receive the latest information to guide their delivery of the best possible patient care.

eClinical Works – Girish Kumar Navani, CEO and co-founder

There was not enough emphasis on clinical decision support or interoperability. Many are nervous because intuitive clinical decision support is difficult to develop; however, it serves as the basis for a good prevention-oriented EMR. We would have liked to see more focus in this area and raise the bar for clinical decision support as a requirement for EMR use.

Eclipsys – Philip M. Pead, President and CEO

We consider the threshold for Clinical Decision Support (CDS) is clearly a token gesture in Stage 1, and will require a much better definition of what does and does not qualify as CDS before this criteria can become measureable.

What’s important to note is that the landmark Institute of Medicine report, “To Err is Human” was published approximately 10 years ago, calling for expanded use of CPOE to reduce avoidable medical errors and deaths. We believe the passage of ARRA is an unprecedented opportunity to move forward the quality and safety of care for all of us. We agree a one size fits all solution for CPOE isn’t the right approach and we believe the initial ARRA definition timeline gave physicians and hospitals ample time to appropriately customize their adoption of clinical decision support tools. As healthcare leaders we know meaningful CPOE adoption is achievable and we don’t understand what would merit any delay in implementing a technology that prevents human errors and has been proven to reduce costs, injuries and deaths.

e-MDs – Michael Stearns, President and CEO

We have for many years viewed decision support as a key added value associated with HIT adoption. We currently offer warnings related to drug-drug interactions and allergy-checking, drug-disease contraindications and formulary support in our e-prescribing module. These features, in addition to the use of health reminders and the five clinical decision support rules relevant to the quality measures is in our opinion sufficient for Stage 1 meaningful use.  Regarding interoperability, in the future we would like to see a little more emphasis on data integrity in HIEs.  We fully support the need for information to be stored as machine processable structured data.  However, given current standards and methodologies, we have concerns over how this information can be safely shared in information systems without an independent validation process in place.

GE Healthcare – Vishal Wanchoo, President and CEO, GE Healthcare IT

There was strong emphasis on clinical decision support. It’s no secret that we have advocated for a robust level of interoperability as part of “meaningful use” and standards and certification. As a company and an industry, we have been focused on adopting harmonized interoperability standards in a logical stepwise progression.

Since we saw the initial meaningful use proposal, our concerns have remained centered on the underemphasis of standards, interoperability and health information exchange in the meaningful use criteria.  On initial review, we’ve noted the companion standards and certification criteria rules contain a scaled-back set of standards for interoperability and security.

InteGreat, a MED3OOO Company – Tom Skelton, President

We believe so. Decision support can take many forms, and most products today have some degree of this functionality included. The real question is how the physician interfaces with this functionality. Our clients have told us that numerous pop-ups flying in the physician’s face is not only annoying but can lead to a complete disregard to alerts that appear. Too many alerts can result in a critical alert being missed resulting in a patient care incident. If meaningful use includes a tracking of physician use of this functionality, we need to ensure that it is balanced so as not to make excessive use of a good thing. Given the lack of standardized coding for the majority of clinical elements, the hurdles for higher levels of decision support and/or interoperability are difficult to achieve. As such, the next step before requiring greater decision support or interoperability is a mandate for the use of a standardized nomenclature.

McKesson – Dave Henriksen, SVP and GM, Physician Practice Solutions

The decision support requirements increased significantly between the HIT Policy Committee’s summer recommendations and the December proposed and interim final rules. The original recommendation was to implement at least one decision support rule, but now the requirement calls for five rules. So that certainly is a much greater emphasis on decision support as “a critical aspect of improving quality, safety, and efficiency.” Some of the decision support requirements will be challenging for providers and vendors alike and need clarification.

From an interoperability perspective, we will recommend robust requirements. The sharing of clinical summaries (problems, allergies, meds, etc.) is still required for transitions of care as expected. However, the immunization registry and public health agency reporting requirements call for the ability to “perform at least one test” for connectivity. While this lowers the burden on providers/hospitals, vendors must enable their systems to comply whether it’s a single test or daily feeds. This means some health systems and physicians may believe that rudimentary point-to-point connections may be sufficient. However, in the long run a point-to-point method will be difficult to maintain and will not provide the robust network connectivity foundation required to achieve the larger national goals.

NextGen Healthcare – Scott Decker, President

The parameters set by the federal government are in line with what the President originally outlined, and a good start toward achieving the ultimate goals of ARRA. We view health information technology as the means to improvement in our healthcare delivery system, and not the end result. From that perspective, the meaningful use criteria establishes the right foundation for physicians not only to implement technology but then to use it for the delivery of better patient care through timely and accurate access to key health data on individual patients. With the detailed requirements included, the federal government is challenging doctors to create a healthcare delivery system that is more clinically efficient, financially responsible and patient-accessible than it is today.

Sage – Lindy Benton, Chief Operating Officer

These are really two separate questions, but in both cases, there’s a delicate balance between the end goal and where the market is today.

The intrepid new EHR user is looking to accomplish some basic goals that are meaningful to the physician. Though in many cases these goals overlap with certain meaningful use criteria, we are often looking at something more basic than clinical decision support. Once they have accomplished these goals, the question becomes: “OK, so what else can EHR do for me?” So, from that perspective, the requirement to implement a single rule is a good start and prevents clinical decision support from becoming a workflow distraction rather than an enhancement.

Similarly with interoperability, an incremental, proof-of-concept approach makes sense given that medical communities are typically fragmented and it is rarely the case that a comprehensive HIE exists. Sage has been at the forefront of what has come to be called interoperability, from early lab interfaces, to e-prescribing, to our present ability in Sage Intergy EHR to share a CCD with any entity capable of receiving and consuming it. We’re going to be right there with providers developing and taking advantage of opportunities for meaningful exchange

SRSsoft – Evan Steele, CEO

How much is “enough”? The government wants to achieve a return on the investment it believes it is making in healthcare IT. Having access to massive amounts of clinical data and having the ability to share that data across providers are seen as ways of doing this. But the industry is too far behind the automation curve in terms of infrastructure, networking, and repositories to take that big a step at the outset. By Stage 3, beginning in 2015, the hope is that many of those technologies will have been built out to make decision support and true interoperability viable. The question is: Will providers be willing to accept lower patient volumes and financial penalties to comply over the next 5 years?

For Stage 1, it was clear that CMS wanted to kick-start requirements for clinical decision support—the requirement was increased from implementing one decision rule to five. Not only do physicians have to implement each rule, but they also are required to track their compliance with each rule. How much time and effort will that take? No one can even guess yet. Again, more documentation and reporting will be required. And even if this is done successfully, there is no infrastructure in place to do anything with the data or provide evidence-based guidelines on it.

Interoperability is not within the control of physicians, and existing EHRs do not possess the capability to exchange data electronically, nor is the existing infrastructure of HIEs and registries consistent or sufficient across communities around the country. Interoperability is clearly slated for the future, and will not become even a remote possibility until at least Stage 3.

Important to note: Not one of the hundreds of stakeholders and bureaucrats who have shaped, debated and voted on these guidelines has done anything to vet the realities of EMR deployment up to this point. Specialists and other high-performance physicians have experienced it worst: the high failure rate (there are no cited landmark studies that conclude EMR improves healthcare, reduces risk or decreases costs while there are dozens of studies that conclude the opposite); the low adoption rate achieved up to this point; the unacceptable productivity impact on providers; and poorly designed products that force users to be data-entry clerks as much as physicians. Why is it that this initiative assumes it will suddenly work successfully? Who is concluding that? If this homework isn’t done, this whole program is fraud on the American people. Remember who brought us the $1,200 toilet seats and $800 hammers?