News 9/17/09

From NoExcuses: “Re: EMR sales and ARRA. In a recent conversation with a salesperson from an EMR vendor, he mentioned that many docs are are holding off on purchases because they fear the government will find ways around paying the money. Sounds like a crazy excuse; then again, doctors aren’t always reasonable.” At first blush it sounds like a lame excuse for not making one’s sales numbers. Then again, at the eCW conference, John Halamka described the struggles his hospital had getting physicians to move to EMR. After the hospital agreed to pay 85% of the cost, doctors still felt that having to pay 15% of the cost was too much. Then, the IPA figured out a way to pay the 15%, essentially making the EMR free. Free was not cheap enough for many doctors. It was not until the government said they’d pay the physicians up to $44,000 did they decide the price was right. Thus, it’s not surprising that plenty of doctors are still looking for excuses to avoid EMR, especially when most of them are not lucky enough to have a “free” EMR option.

Athenahealth puts its reputation and checkbook on the line, announcing a guarantee that physician users will qualify for HITECH incentives. If the athenaClinical physicians fail to qualify for the 2011 incentives , the company will offer them six months of free service. Athenahealth claims their Web-based, shared risk service model gives them a vested interest in physicians earning bonuses. In addition, their software platform allows them to tweak the rules engine in ways to force physicians to meet HITECH program guidelines. I’ll bet that physicians who had never before considered athenaClinicals will at least give it a look.

Bay Area Orthopedic Surgery and Sports Medicine (CA) selects Prime Clinical Systems’ Patient Chart Manager.

RCM provider Capario achieves full HNAP accreditation from the EHNAC.

The Association of Departments of Family Medicine wants new family practice physicians to be better prepared to use HIT, with their educators training them to use EHRs to facilitate clinical decision making, communicate with their patients, and interpret data.

The Health IT Standards Committee submits its recommended EHR privacy and security standards. The initial set is basic, but by 2013, EHRs would be required to use HL7 BRAC role-based access control, security assertion markup language, and WS-Trust for secure exchange of Simple Object Access Protocol messages.

Good news on the effectiveness of electronic prescribing. A study published in the Archives of Internal Medicine concludes that prescribing alerts in ambulatory care may prevent a “substantial” number of injuries and reduce healthcare costs. However, only 10% of drug interaction alerts accounted to 60% of the ADEs and 78% of the cost savings, suggesting that systems should focus on higher-level alerts and reduce alerts with nominal clinical value.

I’ll never tell if I wrote this or if it was one of my BFFs. In any case, it made me laugh.

SXC Health Solutions and Allscripts team up to enhance the e-prescribing options for SXC’s healthcare benefits management customers. EHR and e-prescribing clients of Allscripts will be able electronically receive data from SXC clients, including details on eligibility and medications.

Nuance Communications announces that eClinicalWorks and McKesson Practice Partner have successfully completed Nuance’s Dragon Medical EHR Certification program. Speaking of Nuance, I chatted with those guys earlier this week in Vegas. There was a suggestion that the company may still have an acquisition or two in the works.

A California bookkeeper is charged with stealing almost $1 million from Conejo Valley Women’s Group (CA). Elizabeth Ann Jones worked for the practice for 18 years and allegedly forged and issued hundreds of checks to herself, her creditors, and family’s creditors.

Two pet peeves that have crossed my mind in the last few days. First, answering your cell phone during a speaker’s presentation. Two, Web sites that require you to register before you can see any sort of demo. There. I feel better.

E-mail Inga. 

Update from eClinicalWorks Conference 9/15/09

I’m heading home today, after a quiet Monday evening catching up on emails and the like. Well, I did go down to the casino long enough to feed the slot machines another $20. And had a couple of glasses of wine and a good dinner. Before leaving the hotel this morning I had breakfast with a few users and listened to their impressions about the conference and eClinicalWorks in general.

As mentioned in a previous post, ECW’s biggest challenge will be to beef up its support. While users will tell you the product is great and much less expensive than other EMRs with comparable features and functions, they will also complain that it takes too long to get issues resolved. And then users will also say they value the 24/7 live support that ECW provides at no extra charge.

My breakfast-mates relayed stories about new releases not functioning correctly and of frustrations that desired features always seem to be promised for the “next” release. And that they did not receive adequate training. When I asked them their experience with other software vendors, they agreed ECW was not the only vendor they have known to have problems with support and product QA. And, I was told their doctors do not want to pay additional money for training. And, as users, they were too busy to learn new functionality on their own. I say this, not in defense of ECW as much as to remind all of us that no vendor is perfect. No one has come up with the perfect model for support/QA/and training. If a company had, they’d have the market cornered and we’d have more than 20% of physicians using EMR. It takes time and commitment to maximize the use of software, whether it be ECW, Cerner, or Microsoft Excel.  The government can throw billions to the industry, but that doesn’t change certain fundamental “truths” about software, physicians, and vendors.

Meanwhile, back at the Venetian, ECW was busy releasing press releases. ECW now has a west coast presence, opening an office in Pleasanton, CA. The company also shared news of its  new patient-record sharing tool that will allow ECW users to electronically share medical information with other ECW practices,as well as third-party EMRs. Finally, Children’s Hospital Boston and ECW are collaborating to combine patient data from their ambulatory physicians’ systems and the hospital’s Cerner EMR.

I’m leaving Las Vegas…

E-mail Inga.

From the eClinicalWorks Users’ Conference 9/14/09

Monday morning started off with a panel of keynote speakers, all with great messages about meaningful use, EHR deployment, and improving quality care with EHR. William C. Biggs, MD, a physician and eCW user, shared how EMR has helped increase his productivity and created efficiencies. Next up was Jesse Singer, DO, the executive director of development for NYC’s Primary Care Information Project. An impressive 1,500+ physicians are now live on eCW, which surpasses the project’s original three-year goal of 1,200 physicians.

Micky Tripathi, PhD of Massachusetts eHealth Collaborative gave a high-level overview of ARRA and meaningful use, followed by John Halamka, MD (in black) with a more nuts and bolts “what does it all mean to me” type presentation. The group were as high quality a team of presenters as I have seen anywhere. Perhaps I was mildly partial to Halamka because he did an excellent job breaking down a complicated and potentially boring topic and presenting it in easy-to-understand terms. Plus he seems generally passionate about HIT and is pretty cute.

I did a quick pass through the ECW training and support area and liked this cool public art project in the works. The final products (at least three, I believe) will be donated to a yet-to-be-determined children’s hospital.

I also realized that ECW is offering actual training sessions for participants at no additional charge (versus the $150 an hour you would pay to have someone come onsite).

Here is something you don’t see at every conference: a dedicated “prayer and meditation room”.

As mentioned yesterday, I talked to some of the exhibitors yesterday, including the folks at Medicity. I realize they are a sponsor and all, but really, these guys are just plain nice. Their customers are primarily health systems and HIEs, but they felt their participation was worthwhile because it gave them a chance to educate physicians about their offerings. Several clearinghouses are here, all competing with one another for that piece of business from ECW clients. Similarly, Fujitsu and Panasonic were each displaying their respective tablet offerings. One ECW person told me that they try to be as “vendor neutral” as possible, which I am sure vendors both love and hate.

Yes, I have seen plenty of fun shoes.

This afternoon I had a chance to spend a few minutes chatting with eClinicalWorks CEO Girish Kumar Navani. I found him to be down to earth, engaging, and excited by his company’s growth and the success of the conference. We discussed everything from the Walmart relationship (very strong) to customer support (always a struggle but much better than it was two years ago) to his philosophy on pricing (rather than pricing a product based on what the market will bear, figure out the cost and mark it up a set percentage.)

He admits some amazement over how much the conference has grown — attendance this year is about 2,200 compared to the 1,200 who attended last year’s first conference. The attendance figure is especially impressive when you consider that eCW has only one product used by about 30,000 physicians; many of their competitors have far bigger client bases, more products, and user meetings of comparable size.

I hadn’t given this much thought before, but I believe eCW’s “one product” approach contributes to the company’s success. All R&D is directed to the one software product. The company does not “waste” resources to sell PCs for a 5% markup. No clearinghouse, no inpatient system, no legacy systems, no hardware support. Just focus on a core competency. On the other hand, clients — especially those in smaller offices — are likely frustrated when support can’t help them figure out why their EMR keeps locking up on one particular tablet PC.

All in all, the company seems to be doing something right. Advertising is practically non-existent (though they support HIStalk because Girish is a big fan). Girish believes that if every happy client tells five people, they will continue to grow. He claims the recession has not slowed their sales, nor have they seen doctors delay purchase decisions over ARRA meaningful use concerns.

A user told me today that the first eCW person to step into their office was their trainer. All the demos and negotiations were done virtually, which certainly saves a few pennies. And as for the Walmart relationship, it has opened doors for many larger opportunities, so Girish views it as a clear success. (Interestingly, WalMart gets next to nothing for the ECW portion of the sale).

Girish told me that when the conference is over Tuesday afternoon, he and 80% of his staff plan to stay until Wednesday. He expects his staff to keep their Vegas experience in check until the convention is over and then he will be celebrating with the rest of them. I respect a leader who likes to work hard AND play hard.

More updates to come.

E-mail Inga.

eClinicalWorks Users’ Conference 9/14/09

Vegas, the Venetian, and a chance to see John Halamka. Well, it was all too much to resist so I picked up and headed to Las Vegas. I arrived Sunday a.m. and headed directly to the hotel. After a relatively quick check-in, I got my ECW badge and became an official attendee.

ECW has about 20 sponsors in their exhibit hall, which is located directly behind the check-in booth (which surely helps booth traffic.)  Front and center was Dell, healthcare’s newest source for EMR solutions. ECW, of course, is Dell’s first partner in its Affiliated Physician program. I am sure there is no coincidence that Dell made the announcement on the eve of ECW’s meeting.

I had just enough time for a quick tour of the exhibit hall (more on that later) before lunch was served.  Round tables were set up in the back of the exhibits and boxed lunches could be picked up on side tables. I must admit I liked the informality of it. Attendees could sit wherever they liked and had an hour to network. I sat with some folks from the Midwest, who had mixed opinions on Girish’s opening address (which I missed.) He is apparently a very good speaker, and reviewed ECW’s first 10 years and a variety of new releases and products in the works. He also re-iterated the company is not going public. The one critic at my table feels support is ECW’s biggest weakness and was disappointed that Girish brushed over the topic too quickly.

Then, on to some sessions.  I sat in on a presentation by two two physicians from Children’s National Medical Center in DC. The pair led the initiative to promote EMR use among their physicians and spoke on EMR adoption barriers in primary care. The hospital promotes ECW in a subsidized model designed to provide physicians with “great pricing, a great product, and good support.”

Next, I attended Dell’s session that explained their affiliated physician program. Though less than 100 people were in the room, several seemed to have connections with health systems and expressed interest in the Dell alternative. I also spoke to an ECW reseller who had some doubts, viewing the program as a threat and wondering if Dell truly had the expertise necessary to jump into the support role.

I won’t mention the third session I attended, other than to say that if you don’t have an engaging speaker, it’s difficult to stay awake in a dark meeting room.

On the other hand, kudos to Paul Logan, who led “Dragon Medical Stinks and 9 Other Exaggerated Myths.” I didn’t know many of the ins and outs about Dragon before, but he was an fun presenter who kept my attention. Who knew that Dragon 10 supported seven different accents and about 70 specialties? I’m impressed.

I then hiked to my room (the Venetian, like most of the Vegas hotels is huge.) I had heard the rooms were big, but I swear this is larger than my first apartment. Three flat screen TVs, a fax machine/copier, and a bathroom big enough for half the Dugger family. After a quick refresh, I joined the ECW-hosted dinner.

It’s tough to serve 2,000 people at once and keep them entertained. I sat towards the rear and I could not understand anything the speaker was saying (I think they were having some sort of game while salads were being served.) The Venetian did their best with a chicken/fish plated dinner, but it was lacking. Good thing I saved room for dessert, which was a fancy chocolate and custard combination.  More entertainment was promised post-dinner, but I headed to bed early.

Only in Vegas.

It’s now early Monday a.m. I went downstairs for a coffee and crossed paths with several folks drinking beers.

Yesterday afternoon I popped into a shop for a bottled water and observed a small wedding party making their beer and wine selections. Why not?

Alas, I have to admit I  lost $20 at the slot machines. Just helping the economy, I suppose.

First day impressions

• The biggest complaint I have heard from users is that ECW has some support struggles. As one practice administrator told me, we are a society that is used to instant response: when we want to know something, we jump on the Internet and find the answer immediately. ECW has grown quickly and it’s been tough for their support to keep pace.
• Another comment heard more than once is that new software is sometimes released without adequate QA. On the other hand, users appreciate that ECW is constantly enhancing the product and providing regular updates.
• Users seem quite loyal. Though they say the product and company is not perfect, I have not talked to anyone who has suggested ECW was not the right choice for their practice.
• ECW appears to be committed to transparency. For example, they extended an invite for me (and Mr. H) to attend, knowing full well that we would report on the good, bad, and ugly. Also, I have met a number of prospects attending sessions and networking, without an ECW representative at their elbow diffusing any negative comments. I like that.
• We have all been to those fancy, smancy conferences where every moment is perfectly orchestrated. That is not the case here. Instead, the atmosphere is more relaxed and focused on promoting networking and learning.

More later.

E-mail Inga.

Joel Diamond 9/14/09

Random Thoughts from a Traveling Physician

Maintaining a private primary care practice while being a healthcare executive for an international company is both rewarding and challenging. Travel and interaction with doctors and nurses in diverse environments is extremely valuable in gaining new perspectives on healthcare, but often requires creative processes to remain accessible to my patients back home.

A few weeks ago, I was waiting on line to board an airplane in Pittsburgh. By chance, several of my patients were on the flight. One reluctantly told me that he felt guilty about not scheduling his overdue colonoscopy and another mentioned his need for prostate exam. A stranger who was in line, actually asked me if I “enjoyed doing that kind of thing” and should he be” nervous” with his own doctor. I couldn’t help but reinforce his anxiety by saying, “Only if you feel both of his hands on your shoulders during the examination”.

When I finally took my seat, the gentleman next to me said, “I couldn’t help hearing those people talk to you. It must be strange running into patients like that.” Thinking that this was going to turn into a conversation about accessibility and dedication, I was disappointed to hear his next question. “How does it feel when people see you and only think about their ass?” Oh well, so much for the glamour of a traveling physician.

On a recent trip to the Netherlands, I took my 16-year-old son with me, hoping to enrich him culturally. Unfortunately, our brief stroll through Amsterdam’s famed Red Light District became the prime focus of discussion when talking to his friends back home. My wife still quizzes him about details of the Anne Frank House and Reikmuseum just to see if we really did doing anything truly cultural.

The truth is that one must turn every situation into a meaningful learning platform for teenagers. For instance, when my son noticed a leather-clad prostitute wearing a dog collar casually sitting in her shop front window, I seized the opportunity to point out that she paid income tax on her earnings along with a 19% VAT on each client. (Annoyingly, he challenged her clients’ ability to maintain invoices for services). Undaunted, I persisted by launching into a discussion about Dutch healthcare. I pointed out that, like all Dutch citizens, she is covered under a universal healthcare policy that she pays for by both private payments and taxes.

All joking aside, Jonathan Cohn, a senior editor at The New Republic, wrote recently about satisfaction with universal healthcare in Holland. His observations align perfectly with my own. He points out that in Holland, most people have long-standing relationships with their primary care doctors, and 60% of them can get a same-day appointment (compared to the US, where it is only 26%). And while the Dutch spend only 10% of their GDP on healthcare, they rank substantially higher than the US in several key indicators of health.

This really got me thinking about the whole issue of accessibility in heathcare. While walking along Amsterdam’s beautiful canals, I was actually interrupted twice by patient calls from back home. It was bit surreal to e-prescribe on my BlackBerry while so far away. Clearly technology, if used properly, is a key to patient-physician accessibility. Having access to my patients’ records through an EMR plus interoperability with the hospital IT system allows me to care for patients even during travel, but it is my patients’ access to my cell phone that makes them feel that I am always available to them. 

Now I know what you’re probably thinking — “access to cell phone!?” Yes, I know … this is not the norm, but it is precisely why my patients can tolerate my unusual schedule. As is the case with the Dutch, the issue of accessibility should not necessarily be a detriment of universal healthcare, but attitudes and processes must be creatively changed, much like in my own practice.

Flying home recently, a complete stranger sitting next to me was complaining about his elbow. It was red and swollen and I casually asked him if he was going to get it taken care of immediately when he landed. “Should I?” he asked. I told him that he had a fairly significant olecranon bursitis and it appeared infected. I explained that it would likely require drainage of the fluid plus antibiotics. He thanked me for the advice, but then looked at me and asked reluctantly, “I didn’t think to ask, but without insulting you … you are a doctor, aren’t you?” With a straight face I answered, “No, but I did stay at a Holiday Inn Express last night”.

Joel Diamond, MD is chief medical officer at dbMotion, adjunct associate professor at the Department of Biomedical Informatics at the University of Pittsburgh, and a practicing physician at UPMC and of the Handelsman Family Practice in Pittsburgh, PA. He also blogs on interoperability.