HIStalk Practice Interviews Jonathan Bush 9/23/09

Jonathan Bush is co-founder, CEO, and president of athenahealth.

Tell me about the new guarantee and what it encompasses.

The goal of the guarantee is to try to point out the differences between buying software and solving the problems of medical records and billing. So what that guarantee says is that if for any reason you, as a user of athenaClinicals, do not get your payments, we will credit, you even if our technology works properly.

You will get whatever it is, six months free, or some sort of multi-thousand dollar benefit, which amounts to multiple years of profit to athena in exchange for a goof of any kind, whether it be staff not trained well enough or whether it be related to the government — whatever. That’s exactly the kind of guarantee that key providers in healthcare ought to be giving.

Why do it? How can you do it?

The whole point is: how can we do it? How can we do something when the rules may change year to year? How can we know that we will comply? The point is, we better. The rules work into the cloud. You move the work, whether it could be done on software or not. You move the knowledge that you needed to know what the work is. You move all of the haggling and struggling necessary to compel results.

athenahealth is the only company that takes all those things to deliver success in moving your medical records online. They don’t deliver various electronic tools which may or may not result to any success. This is just one of many examples.

I’m hoping in time there will be more and more guarantees like this: guaranteeing that it won’t go slow, guaranteeing that you won’t lose your data, guaranteeing that when patients start to move to patient health record, that you won’t incur additional costs. Guaranteeing that if there’s money to be made by exchanging information, that you’ll make it.

We don’t know what those guarantees are yet, but the whole point is to keep pushing on the differences until people give up on this kind of this idea of running their own microscopic-scale processing organization.

Why aren’t other companies making the same offer?

I don’t believe that any other company even endeavored to know all the rules and change their software accordingly. I don’t believe any other company endeavored to correlate clinical information to payment information and actually have the infrastructure to get the payments in.

What is unique about Athena is that everything — the single principle that organizes all the work we do — is that we’re the best in the world at getting doctors paid for being their best self. So if we’re going to do a medical record, we better be able to prove how to get doctors paid more than not having a medical record for being their best self.

That means we need to figure out where the money is. Is it from the government? Is from various pay-for-performance programs? Is it from eliminating faxes? Is it from eliminating staff? And then we’ve got to make sure those things actually happen, which means it will take a lot longer when you think about it.

We’re pretty good at writing software. We’ve had a working electronic medical record for five years almost. Ninety percent of the work we’ve been doing on athenaClinicals isn’t on the clicky-click on the front of the electronic medical record. It’s connecting up our ability to collect knowledge and do research with insurance companies and our ability to connect information into payment and to put that payment in the bank and to reconcile it against what we expect to get.

Doing all of that, making up a whole new revenue cycle, has taken five years. Nobody else has gone and made up a whole new revenue cycle. And if there isn’t a revenue cycle attached to medical records, why are doctors supposed to do it? Because it’s their mercenary duty? Why doesn’t somebody else do it? It’s not fair.

If it’s something that’s so valuable to society, that we simply let our arms fold and look down our noses at doctors for not losing twenty percent of their revenue to do this. It’s so petty of us. Of course they should do this, and of course we’re going to pay.

What has the reaction been from the market so far? I know it’s just been a couple of days, but …

The great tragedy of the healthcare market and the real market — when you say the market, I mean the world of medical providers – the stock market analyzes 17 ways to Sunday, it ripples through the street, everyone knows about it. But the real market, which is the market of providers — and this is why Mr. HIStalk and you are so important – is that nobody knows nothing. Nobody knows that we exist, and here we are making guarantees, and people are saying, “You are guaranteeing what? Who are you? Who’s Obama?”

Our target market is in there seeing patients. So I don’t know. Hopefully the market will at least know that we exist at the end of this at a minimum. Maybe they’ll all get on to the network, get rid of their software, get rid of their overhead, and start making money. But at least they’ll know we exist. I’m very glad for that.

Athena’s strength has always been on the revenue and collection side. Do you think the new program is going to attract the attention of those physicians who never before thought of athena as an EMR player?

Why haven’t we really compelling EMR for five years? Because we have another compelling reason to know how we could make doctors more money. Now, if every doctor that gets on athenaClinicals doesn’t make more money, I’m going to want to know why.

I believe that every single doctor that we give a proposal to on athenaClinicals will actually make more cash as a result of being on athenaClinicals than not. I couldn’t say that for five years, and I still can’t say that about any of the other software products that I’ve seen. My whole gig is that no wine before its time and we may have lost a couple of years doing this and our reputation is more known on the claims side.

But better to wait and then chirp around like a rooster when you’ve got something to chirp around about. Otherwise pretty soon people will think you’re kind of a BS-er.

Not you. [laughs]

Not moi. That is impossible.

How many athenaClinicals physicians do you have right now?

We had a big spike with when the government came out with the stimulus package. Most of our major enterprise customers right now are a mix of pretty significant roll-outs of athenaClinicals. We’re expecting that number to grow at multiples of the company growth rate. It’s pretty exciting. In fact, I just authorized ten budget hires for clinical implementation folks yesterday because they’re all flat out and still not covering demand.

Anything else you want to throw out there?

It’ funny, because I have to say I feel a teeny, tiny bit guilty for making hay on this and being so good at what we do, because it just points out the fact that people have to do this in healthcare in our country. It’s such a bummer.

Can you imagine auto insurance where getting gas required an auto insurance claim? Or changing your oil? It’s just so amazing that we’ve complexified, just inadvertently slipped into this unbelievably overpriced, inefficient non-transparent system. My only hope is that the reason I don’t burn in hell at the end of all of this is that I made it more transparent.

The fact that I have profited so much and all of us athenistas have easily profited so much in its complexity — I still am confident that we didn’t start it, and we’re ending it. It makes me feel good.

I have to say that just because this thing is going to be incredibly good for athenahealth, I don’t think it’s going to be a good idea. Just making up more rules and more complexity for consumers and doctors and everyone to have to understand. I think we should be going in the other direction.

What kind of additional resources are you having to dedicate to build all these rules into the process?

It’s a good question. We don’t know the frequency of change yet. We know that what Dr. Blumenthal said that we can expect some changes every year due to rules.

The other thing is that we’ve identified, since getting into this guarantee and this product approach, 36 other programs today that pay sometimes more than the HITECH act states. We intend to onboard all the rules for all of those programs and enroll all of our clients in all of those programs.

So it’s not just a HITECH act. The staffing will have to expand to accommodate all of the programs that emerge, and the commercial sector as well. And the answer is we just don’t know. But we’re OK with that. We know that it will lead to differentiation, and so we know we have to do it. We just have to have our planners ready.

Jeremy Delinsky will lead the group a division called athena Intelligence Group, or AI Group. He’s in charge of all the researchers and analysts and developers that deal with these rules on the revenue cycle and the clinical cycle side. We’ve got a wonderful new director who’s in charge of clinical intelligence and they are ramping up a team

We always have a lot of those kind of candidates. We’re in Boston. We’ve got a lot of MIT, Harvard, Brown kids that are interested in doing something important in the world, good bench perspective analytical types to work at the company and help the demand rise.

Right after we interviewed Jonathan Bush, a reader sent this comment, which we forwarded to him for a response:

athenahealth’s guarantee is a great marketing scheme, but be sure to read the fine print contained in the FAQ section. The burden of demonstrating meaningful use still falls entirely on the physician. One of the requirements to take advantage of the guarantee is that the physician must “actively use our solution to meet the ‘meaningful use’ criteria.” Buried in one of the last questions is the following exclusion: the guarantee does not apply to “any physician who fails to meet … specific required quality or administrative outcomes with specific performance goals.”

So what exactly is it that athena is guaranteeing? Same as the other vendors who promise that their software will continue to meet the HHS certification criteria. No one can guarantee that a physician will or can demonstrate meaningful use, or that the government will agree that they have. Also, it is important to note that the guarantee is limited to six months of services. The physician would have to pay athenahealth up front, wait to see if they qualify for the incentive and meet athena’s requirements, and then hope to get a refund. If they do not like the software and cannot demonstrate meaningful use, they are stuck with an EMR and a lost investment.

Jonathan Bush’s response:

I was bummed to see some of our fine print being read as a wiggle out. The intent of this language was to express the limit of our abilities to warranty health outcomes — for instance, if a measure were to be written as “80% of diabetics must have a1C levels below 7” to qualify for funds, it’s pretty clear we can’t guarantee this. Another way of saying this is that our docs are still responsible for doctoring.

It is important to note that we only did this because the measures aren’t known yet. We really don’t expect any of the measures to written this way until the out years. The only other scenario this language was intended to cover is a specific administrative measure likely to be included that requires physicians to certify: 1) that they abide by all privacy and security laws; 2) that a formal privacy and security policy is in place and reviewed annually. We are accruing real money in case we have to pay on this. And that is because we are taking real responsibility for end results.

News 9/24/09

From Grizzled Veteran: “Re: the SSA wanting to purchase an EHR. This is a mess. The pilot is six locations; the total will be 30 locations. Amount to be awarded not to exceed $25 million. The system will be selected off the RFQ — no demos of the software before purchase and it must be ‘live’ 30 days after the contract is awarded. Are these people serious ? Inga, can you watch this and let us know who was awarded the contract … if anyone?” I checked out the RFP for myself and I must say the SSA is not making itself easy to do business with. Grizzled Veteran didn’t mention that the 68-page RFP was sent out September 14th and the deadline for completion was September 18th. The site lists 54 “interested vendors” and eClinicalWorks is the only mainstream EMR name I recognized. Seriously? Either they already have a vendor in mind (bet on that) or they don’t really want an EMR.

PracticeOne and SyntegraMD announce a partnership to to integrate the PracticeOne EHR with SyntegraMD’s office and lab management services. The combined solution with provide practices with a single source for diagnostic and imaging lab results, communications, and EHRs.

EMR and PM software vendor gloStream contracts with Apollo Health Street to provide gloStream clients an additional IT support option.

Allscripts now has its own online channel on ehrtv.com, which features extensive video documentary of this summer’s ACE09 conference. Check it out here.

Link High Technologies, by the way, announces it is now a certified partner and reseller of Allscripts MyWay. Link High will sell the integrated PM/EHR solution throughout New Jersey.

HIMSS announces the 2009 Davies winners: MultiCare Health System, Tacoma, WA (organizational); Virginia Women’s Center, Richmond, VA (ambulatory); and Urban Health Plan, New York, NY and Hearts of Texas, Waco, TX (community health).

Practice Fusion (the free EMR guys) partners with BioReference Laboratories. The companies will collaborate to distribute Practice Fusion’s EHR to BioReference physicians and BioReference lab results will integrate with the EHR. Practice Fusion thinks the arrangement may “effectively double” their user base. Their web site says they have 18,000 physicians and practice managers using their system and that 15,000 physicians utilize BioReference Labs. I suppose a little hyperbole is allowed in press releases.

Quest Diagnostics takes its own digital stand, offering interested physicians a risk-free trial of its Care360 e-prescribing service for six months. Quest says it has at least 150,000 physicians using Care360 services, including ePrescribing, and Labs & Meds. And here is something cool: the applications are accessible via iPhone/iPod Touch. If you go really deep into the press release you’ll learn that Quest has a new EHR in beta. Care360 EHR is scheduled for release this fall (after they have hooked in all those doctors using free e-prescribing.)

Quality Systems, the parent company of NextGen, appoints Philip N. Kaplan COO of NextGen and the QSI dental unit. Kaplan resigned as a board member in order to take over the COO role. Craig A. Barbarosh, an attorney who specializes in organizational restructuring, becomes NextGen’s newest board member.

GlobalMedia, NeuroCall, and REACH Call introduce a new resource to provide neurological consults to patients in underserved areas. 

Here’s a doctor’s office I am glad I never worked in.

E-mail Inga.

News 9/22/09

From No Free Lunch: “Re: EHR excuses. You seem to be stating that physicians in private practice are looking for a free lunch or free EHR. I think this is off the mark as HIStalk has published at least two analyses that pointed out that the physician ‘stimulus’ dollars are a poor business deal if one is rushing into the fray just to get them. I would not characterize practices as ‘cheap’ but as ‘cautious’.” I agree.  My point was that physicians continue to avoid adopting EMR. The biggest barrier appears to be cost, and in some cases, “free” is not cheap enough. As an industry, we need to ask why this is the case. Is it because the ROI is poor/non-existent? That the potential improvements in quality of care do not outweigh the cost of using a time-consuming EHR? In many cases the stimulus money may provide the tipping point, but that’s probably not true across the board.

From Peeving: “Re: additional pet peeves. Add those that take those registrations and put you on everyone’s e-mail list for solicitations! The Everything Channel got my address, signed me up for "everything", and the Unsubscribe link was blocked by my corporate firewall.” The weight loss spam bugs me. Did some ex-boyfriend sign me up as a cruel joke? Or worse, is my mother try to tell me something?

AmeriHealth says that 75% of all claims are now submitted electronically, which is up 50% from three years ago. I was actually surprised that the number is not closer to 90%, so I guess I am out of touch.

Dell announces it will pay $3.9 billion for Perot Systems. The announcement comes less than two weeks after Dell released plans to expand its healthcare offering, starting with an EMR offering for hospital-affiliated physicians. Given that almost 50% of Perot’s business is healthcare-related, it sounds like Dell is trying to further a stake in the healthcare arena. Not a bad move, especially if Dell wants to be known for more than making and selling PCs.

In Clay City, IN, a family physician relies on his practice’s EMR while making house calls to remote areas.

Webahn launches two new iPhone Apps that target physicians. Capzule is an EMR service that allows physician to access to patient records outside of the office. I don’t think I have ever heard of Capzule, but they offer an EMR for $50 a month via a SaaS model. OvernightScribe allows physicians to dictate notes an letters on the iPhone and sent them to OvernightScribe.com for transcription.

If neither of those applications meet your fancy, Keystone Insights has also launched DocWrite. The free application provides mobile dictation and transcription and allows doctor to dictate patient information to add into an EMR.

Navicure adds Heartland Orthopedic Specialists (MN) and Fon du Lac Human Services (MN) to its client roster.

Phytel releases version 5 of its Web-based Proactive Patient Outreach solution, which Phytel CEO Steve Schelhammer says will help physicians to manage the health of their patients while quality for P4P rewards. We published an HIT Moment with Schelhammer back in June, when he explained some of the ins and outs of the product.

If you are wondering how US healthcare compares to the rest of the word, this article includes a number of “real-life” anecdotes from American travelers. For the most part, patients reported care was good and much cheaper than comparable services in the US.

Piedmont Medical Care Corporation (GA) purchases an additional 230 EHR/PM licenses from NextGen. Piedmont says they are purchasing the licenses in pursuit of the financial incentives being offered through ARRA legislation.

This AMA article encourages physicians to not let their EMR get in the way of the patient/physician relationship. Making eye contact and discussing the technology are two key strategies to ensure patients don’t feel the computer is cutting into their time with the physician. The article also quotes Lyle Berkowitz, MD, an occasional HIStalk Practice contributor.

The Social Security Administration is making plans to develop an EHR for deployment across its 30 employee health centers nationwide. The agency recently published a request for quotes for contract services.

E-mail Inga.

Intelligent Healthcare Information Integration 9/18/09

Pre & Me

A little while ago, I posted a piece where I mentioned my newly acquired Palm Pre. In my role as a grunt in the trenches pediatrician, I am familiar with the terrain of the un-hip. Pediatrics has long been considered the red-headed stepchild of medicine, often used to promote good will and charitable giving, but never funded or reimbursed with the robust enthusiasm provided to surgeons or radiologists. Rural medicine provides yet a further layer of “you’re not really as good as the big guys” to my repertoire of un-hiptitude.

Thus, perhaps it is in keeping faith with my pattern of life choices that I decided to forego any Apple attitude adjustment and buy the underdog Palm Pre. (Well, I also read a bunch and received a great going-under-the-covers review from an amazing hacker I know in Boston who broke down the pluses and minuses of the iPhone vs. Blackberry vs. Pre, but that detracts from my rep of un-hipness, so we’ll pretend I didn’t actually make a smart choice based upon research and investigation).

Despite some initial misgivings about Sprint’s signal coverage and battery life, I continued to push through the envelope of this new techno-toy. After a mere six weeks, I am so very happy to report that Pre & Me are now true BFFs. I love this little guy, plain and simple. I have so much fun with, and am so enabled by, the integrative design of the features and functionality of my new hip-mate (referring to my belt clip carriage of the Pre, not a pretense to iPhone ego equality) that I find myself using my desktop PCs less often. In fact, far less often.

Some of the cool tools even inspire moments of “Pre envy” in my desktops or laptops or pen tablets. I wish they all were as utilitarian and Zen-like in their design considerations. I now see that those contemplatory eggs gracing the desktops of the Palm Pre’s designers added value and some feng shui focus for the chi of these genii.

The battery issue required a few extra chargers around and an enhanced awareness of usage patterns, but the simplicity of the Touchstone inductive charger has such a coolness to it that slapping it onto the sloped, magnetic, easy on/off base is a mini moment of geek fun. Keeping several chargers about has allowed me the freedom to experience in full-blown glory the multi-open-apps power of the Pre. Zipping from tool to toy to tunes is easier than on a PC and finger-flick fun. (You iHipsters know what I mean.)

I still hope the planned cell tower I see on Sprint’s map of coming attractions just outside of my little burg is a sooner rather than later construction project. Still, though my bars are more often 0-2 than 4-5, I’ve had far less connection troubles than the absence of bars initially implied. The value add of this little beauty has virtually blinded me to any continuing cell signal coverage concerns.

The App Store for the Pre is small, yes, but it’s growing. If you’re brave enough to try homebrew apps and open up the developer mode function, there are many more available. I won’t bore you here with the laundry list of cool tool apps I adore as the gazillion iPhone apps available expose the Johnny-Come-Lately limitations of Pre App unhipness yet again.

However, I will leave you with one rather interesting observation. At a weekend business meeting of some pretty amazing techno mega-minds where most were iPhone adept and enabled, and despite a comment or two about my meager little Pre pal, I did catch more than a couple of my iHip colleagues glancing over my shoulder as a finger danced with my new BFF. Perhaps most amusingly, I also heard more than a few quiet wows! leak out, though they were obviously muffled to avoid any loss of iStreet Cred.

PS – Though it isn’t certified compatible, I should note that I am able to access my web-based EHR from my Pre. The Calendar function is limited, but patient data is accessible … not iHip, maybe, but cool enough for this geek in the trenches doc.

“The strongest of all warriors are these two — Time and Patience.” – Leo Tolstoy

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 through http://madisonpediatric.com or doc@madisonpediatric.com.

HIStalk Practice Interviews Justin Barnes and Mark Segal

Justin Barnes is VP of marketing, corporate, and government affairs of Greenway Medical Technologies. Mark Segal, PhD is director of government and industry affairs for GE Healthcare IT. They are chairman and vice chairman, respectively, of the HIMSS Electronic Health Record Association.

These questions were jointly answered by Justin Barnes and Mark Segal via e-mail.

Why should a member organization like HIMSS be in the business of running a trade association like the HIMSS EHR Association? Doesn’t representing both providers and vendors lead to inherent conflicts?

This is a great question. A small group of EHR software provider executives decided to form the Association in 2004 because of an identified need for a focused, EHR trade association that could offer a voice for its customer base as well as its EHR expertise. After considering multiple operating and incorporation options, we selected HIMSS to provide administrative and financial support as well as their legal and compliance expertise in managing trade association operations. Most important, we established and maintain the EHR Association as a fully independent entity on legislative initiatives, public policy and other industry positions.

So, there is no conflict at all. Both the EHR Association and HIMSS have complete independence in working with industry leadership, advocacy on a variety of issues and other activities, and we develop our own expert policies and submissions to legislative and regulatory bodies.

More generally, HIMSS, like other multi-stakeholder organizations, represents a variety of HIT stakeholders and it has processes in place to allow all these voices to be heard and represented in their overall positions. We think that this multi-stakeholder perspective complements the more focused efforts of the EHR Association extremely well.

Small vendors claim that CCHIT over-represents big vendors, giving them undue influence over certification requirements that reflect the products they have already built. Is that a fair accusation? Does the HIMSS EHR Association have that same challenge, especially since only HIMSS Corporate Members were eligible to join and membership is currently closed?

It is not clear how CCHIT could over-represent large vendors since it does not actually represent any vendors. Vendors clearly are critical stakeholders in the certification process and vendor employees do, appropriately, have a role in CCHIT bodies (but not as formal vendor representatives) along with other stakeholders. In seeking to have the vendor perspective represented, CCHIT has drawn from large and small vendors in its workgroups and to serve on the Commission. You need only look at the list of certified companies to see that there are many, many smaller companies with CCHIT certification, companies that have a range of technology and business models, and time in the business, including open source EHR suppliers.

CCHIT participants from vendors have had only a minority say in development of certification criteria. In any event, CCHIT, up through what was planned as its “2009” criteria, has used a transparent process of multiple review cycles to develop and refine criteria that are often very challenging to vendors of all sizes and types. Any and every company is more than welcome to comment on any CCHIT criteria. We all encourage this whole-heartedly. We encourage our customers and all healthcare providers, as well as other HIT professionals to also review and provide their expertise. Multi-stakeholder participation is a critical aspect of an effective HIT or EHR certification process.

An important objective from the inception of the EHR Association has been to have equal representation from companies of all sizes and market focus. Our relationship with HIMSS has allowed us to keep our dues low, with a sliding dues scale based on company size. This approach has allowed us to have members from across the spectrum. Every member gets the same opportunity to participate in workgroups and to run for our Executive Committee. Each member company has one vote on all matters of process and policy. We hold monthly all-member meetings to encourage active participation by all member companies. In addition, we maintain a careful balance between our enterprise vendors and those often smaller companies that focus solely on the ambulatory market. Finally, membership has been temporarily closed as we update some of our operating policies. Nonetheless, we just admitted four new members who had applied before this closure, which we expect to end shortly.

What is the position of the association on Meaningful Use?

From the start of the ARRA legislative process, we have wholeheartedly supported the concept that ARRA incentive payments should require meaningful use of an EHR and not just its purchase or implementation. The Association developed a set of recommendations on meaningful use for ambulatory and inpatient products this past spring that we presented in testimony before the National Committee on Vital and Health Statistics (NCVHS) and in comments to ONC’s HIT Policy Committee. These documents can all be found on our web site at http://www.himssehra.org/ASP/statements.asp.

To recap, consistent with the approach to this concept in ARRA, the key objective of meaningful use should be to ensure that the eligible professional (care provider) or hospital is actually using the features of a comprehensive certified EHR, especially for priority ARRA functions, to improve the quality and efficiency of patient care. To maximize adoption, which really has to come before use, there should be as few criteria as possible consistent with the ARRA framework and policy goals. Practicality and ease of reporting should be primary considerations.

The primary initial goal should be to incentivize as much adoption and use as possible of comprehensive EHRs, consistent with the ambitious adoption goals of Congress and the Administration. To do this, we have to balance the need for accelerated adoption of interoperable, comprehensive EHRs with the need for care providers and hospitals to implement them in a careful and non-disruptive manner.

We have called for HHS to set meaningful user criteria for 2011 and 2012 at achievable levels, with a roadmap for steady uplift over time in expected breadth and depth of use. The general framework adopted by the HIT Policy Committee of two-year increasing meaningful use cycles is consistent with this approach.

We did submit detailed comments on the Policy Committee’s draft proposal. We liked much of the framework but had several specific comments consistent with our overall approach. We stated that 2011 objectives should be based on software and standards that are currently deployed and implemented, especially on the inpatient side, given the short timelines for implementation. This approach has also been taken by federal HIT officials in various venues.

We also commented strongly that meaningful use criteria should support the movement toward standards-based interoperability. Interoperability from the beginning should be measured using HITSP-harmonized standards. Agreeing with many other stakeholders, we stated that the fact that a provider organization is under investigation for HIPAA violations should not be a bar to receipt of incentive funds and were pleased when the Policy Committee responded by changing its initial recommendations.

Our members seem to be taking the position with their customers, consistent with messages from the Policy Committee and ONC, that the meaningful use criteria adopted by the Policy Committee in June should be considered clear guidance on the likely components of meaningful use in 2011-2012, recognizing that there could be changes when CMS releases final proposed criteria in December and then the final criteria in a spring Final Rule. We and our customers are learning to live with this uncertainty, but we have also been consistent in making the point that the industry needs clarity on meaningful use and certification if we are to achieve substantial meaningful use in 2011. We have carried this message to senior ONC and CMS leaders, and they seem to fully appreciate the need for such clarity as quickly as possible while also complying with the requirements of federal regulatory processes.

One of the things that we want to emphasize is the importance of innovation to our members and their EHR products.  Across our membership, we have seen considerable innovation in such areas as interoperability, user interfaces, quality reporting and web applications. At the same time, because our member companies serve the vast majority of installed, operational EHR users, we’re constantly challenged to balance such innovation with the support required by customers who may not be ready to move to our newer platforms and releases.  Both certification and compliance with meaningful use requirements provide incentives, drivers really, to move EHR developers and users forward on the latest technologies and tools. At the same time, we are pleased that evolving approaches to meaningful use and certification will provide increased space for product innovation by focusing on higher level features and functions. 

These questions were answered by Justin Barnes via a telephone interview.

HITECH was supposed to be a quick stimulus package. Is it likely that those practices that haven’t got started and are waiting on meaningful use definition are really going to have time to select a product and to get the implementation resources to meet the deadlines?

Most certainly. I feel that even when the interim final rule comes out later this year, there’s still going to be plenty of time and place for practices to look at companies that have been involved in this process since the beginning and have the track records.

Following meaningful use and the new ARRA certification is very important for companies as well as for consumers, or the practices in hospitals across the country.

If you look back, you’ll look at companies that have been involved for the past several years in the CCHIT process, and probably even involved in the legislative process on Capitol Hill. You’re going to see that some natural leaders will emerge, and you’ll see products and solutions that are usually at the forefront will probably still be at the forefront.

That can help guide people even in these initial stages. Then once the interim final rule comes out and they have these processes solidified around meaningful use criteria and product certification — a lot of companies have already centered a lot of the criteria that have to be a part of at least the first year here.

A lot of the criteria being created is probably not new that we haven’t seen before in some form or fashion. I think that if the company’s been engaged for a long time, they’re still going to be in a very good position here when meaningful use and the new certification process get announced.

You’re going to have a good support base beginning here. As the official announcements come out with which products and the exact criteria, practices that haven’t been involved in this process so far still would have time to go out and purchase solutions, as well as implement those.

It takes time, because Medicare intends to start “meaningful use” as early as January 1st, 2011. But they still can max out their incentives even if they start in 2012. So there’s still plenty of time for practices, and plenty of resources are still available in the industry.

Even as we begin a groundswell, we do make the statements that you probably want to start earlier rather than later, just because it does take time. But you can adopt meaningful use and EHR probably within six to twelve months, depending upon your practice, and depending upon the product that you adopt, and so there’s still plenty of time.

The Medicaid incentives are really based on the states and their approved plans. We see a lot of those plans probably rolling out Q2-Q3 of 2010 and the physicians and eligible professionals that qualify for Medicaid can work off those state plans that have been put in place.

So I’m still thinking there’s six years to qualify for Medicaid incentives, and you certainly have the first year there to maximize those incentives. There’s still plenty of time to qualify for those incentives if you haven’t started yet. But again, beginning your research now is very important.

If vendors really do get a windfall of business from the activity out there, where will the revenue go?

That’s probably company specific. But a significant amount of our revenues always get reinvested in research and development and innovation. So I don’t see that changing a whole lot. We obviously employ tens of thousands of people as an industry, and we will obviously continue to employ, and that obviously supports the economy.

But a significant amount of our revenues always get reinvested in research and development and innovation. We only see that increasing because we have an industry right for innovation. A lot of us have innovative solutions today, and only look to make those better. Certainly, this gives us an opportunity to continue those investments and obviously continue to employ Americans, which is a cornerstone of our country.

It seems like the market is somewhat polarized into either the high-end, bigger name systems that cost more than hospitals tend to like because it’s a known organization with good support, or the inexpensive simple systems the doctors seem to gravitate toward when they get to pick on their own. How do you think that will play out?

I certainly understand that perspective. I would say that we are going to be entering a new era of meaningful use. There are certainly companies and products out there that have been focused on meaningful use since the start of that company.

But the meaningful use in electronic health record really is the cornerstone to the success of the practice. Using technology and really reaping the incentives, reaping the savings and the return on investment are still used to streamlining their operations.

Having a system that you can adopt and you can utilize at the point of care is critically important. I think that you’re going to see a potential shift from some of those philosophies to really using innovative solutions that allow facilities to achieve meaningful use.

If it is some of the companies that have been around for a long time, then terrific. But I think there’s plenty of room for companies that you may not have heard about for the last three years, but certainly have innovative solutions that are used very effectively and allow for the customers to be very efficient. You’re going to see a lot of those, I think, do very well — certainly the leaders to do very well — and will probably become household names.

How much attention do you think the industry is paying or needs to pay to the usability issue?

I think the industry is paying good attention to usability. Usability is almost dependent upon the practice and their workflow. When you go into research in EHR, it should have always been very important to ensure that solution is usable at the point of care with patients.

Before they purchase their solution, they should always do their reference checks and really ensure that they’re looking at comparable practice sizes, comparable specialty, and ensure that the product is usable at the point of care.

Just because you buy an EHR doesn’t mean you’re actually using it and it’s adding benefit to your facility. You’ve got to make sure you implement it, and you’re buying the right product for your right size, your specialty, to really reap the benefits from it.

I think the market is beginning to properly focus on it now more so than ever before. A lot of practices have always been focused on it. So I don’t think that it’s something we need to overemphasize. I think that the right focus is being applied to it now, but we don’t want to swing the pendulum too far over into certifying components.

Let the customers really manage that. Let them manage their business. Let them manage what they’re looking for. They’re very educated, and they can do that.

It’s interesting that Dell is now wanting in this marketplace. What do you think the perceived opportunities are for big companies that really haven’t done much in healthcare to suddenly decide that that stimulus money looks pretty good, and that untapped market of physician practices looks like a lot of green field in front of them?

About Dell, I can specifically speak to that. Dell has been committed to the healthcare market for well over a decade plus as long as I can remember. They’ve been a very active player. They’re active partners of my company, and they just continue to support the industry to its needs. So I certainly see if there are companies out there looking to increase their focus, that’s because there’s a perceived need.

I believe there is a need. I’m certainly for big partners to step up and really support our industry. We have a lot of growth, and a lot of work needs to be done to support this growth and its focus from a national perspective.

I think companies like Dell are rightly focused, but I wouldn’t say they’re new. Like I said, Dell has been a strong proponent. They’re probably coming more to the forefront in some of their activities, but they’ve been there for a decade plus from my perspective, and will continue that investment on to ensure that we perform the very best services in the industry and are supported with what we need from a hardware perspective and a services perspective.

Do you think they’ll take away market share from anybody or will they just create new markets?

I don’t see Dell taking away market share from anybody. Well — what perspective are you talking about? Are you talking about from a hardware perspective or an EHR perspective?

EHR. If you’re not eClinical Works or whoever eventually their list of partners are, and Dell’s got more of a footprint, do you think that they’ll create enough new market that other vendors who want in on their list of partners will not see any difference, or are they going to push more business into those handful of vendors that they’ve chosen to work with?

Dell was working with probably more vendors than you may have seen publicized in some recent press announcements. Dell’s behind certainly my company and several other companies. I think that if you standardize on a Dell platform or look to, then you’ll certainly have a strong partner for many years to come. I would say that they support their partners very well and they’re looking to obviously support them with all the services and in hardware solutions that those partners in EHR need.

Is there anything else you wanted to mention?

Hopefully we clarified enough the difference between HIMSS as an organization and the EHR Association as an organization. We really do operate autonomously even though we have the HIMSS name before ours, but we really operate as a separate entity.

I can understand that there’s maybe value added to the organizations that have kind of turned the reins over to the HIMSS, like MS-HUG and some of the others, but I guess I’m still not entirely clear on the relationships that go on behind the scenes, or what the synergies are other than obviously those organizations getting a pipeline into some potential new members. I’m uncomfortable with the concept of a trade association being under an organization that claims it’s not, so that may just be me.

I think it’s just that we wanted to operate an association and it would take a lot of infrastructure to go off. We have to create a whole new infrastructure to support that association and HIMSS already had all that experience.

So it really allowed us to begin our organization a lot sooner than spending the time it took to build an association, hire all the staff, train all the staff to run the association, when we are actually busy industry executives taking care of our industry, work at the same time and all the other work we do in the industry.

Being able to tap right into an organization that already had an infrastructure built that we already were comfortable with and understood, at least from an operations standpoint, that was the reason we did it.

We looked at several organizations to do it. HIMSS just happened to be healthcare focused, but there are other companies that had the experience that HIMSS did running a big industry association that we looked at as well.

We decided to work with HIMSS just because they probably offered the most support right out of the gate to get us up and running as an association with a lot of need. We still have a lot of need. We had a lot of need when we were founding it. Back in 2004 is when we officially founded it.

It’s like starting a company — well, starting a company is probably not the best analogy, because you want to really run independently if you’re a company. It’s just sometimes, when you partner with somebody, they have the framework already built and you can just take that and run with it instead of having to build that framework from scratch where it could have taken us a long time.

We had a framework for strategic action that came out of HHS. It really got our industry kicked off on the legislative side and the regulatory focus side, and CCHIT was just coming together. We just had a lot of things happening in the industry that we didn’t want to take the time.

It was just really the most effective way for us to get started fast, and then we just kind of operated from there. It was more an administrative simplicity to get our association. And we are the only association under HIMSS. It’s not like HIMSS does this on a regular basis. We are a very unique operating component of HIMSS. So it’s not all that common.

I wouldn’t expect you to necessarily grasp it because it’s never been done before under the HIMSS organization. I know it hasn’t been done before and hasn’t been done since.

Do you think there’s a point where it will make logical sense for either or both parties to kick it out of the nest and let it fly?

We reevaluate our needs every single year. Certainly you never know what the future holds, but as long as our requirements are being met, we probably wouldn’t change anything. But certainly if our requirements were not being met as an association, then we would certainly seek to have them met somewhere for sure.