eClinicalWorks To Sell PM/EMR Package Through Sam’s Club – Girish Kumar Interview

eClinicalWorks will sell its PM/EMR package in a pre-configured hardware, software, and services package through Sam’s Club. The offering will offer a fixed price package of Dell hardware (desktop PC or tablet), implementation, training, and maintenance.

Sam’s Club owner Wal-Mart will begin selling the package this spring, with prices starting at $25,000 for the first physician and $10,000 for each additional doctor in the practice. Maintenance fees will be $4,000 to $6,500 per year.

Wal-Mart said it approached eClinicalWorks after using its software in its own in-store clinics.

We interviewed Girish Kumar Navani, president of eCW.

If a physician buys from Sam’s Club, will it be the same product, implementation services, and support that eCW offers directly?

Absolutely. We’re trying to make it simple. Everybody says EMRs are hard and implementing change is hard. We realize that. We’ve been doing SaaS since 2003 and have invested a ton on a data center. We wanted system that is ready out of the box, configured, with content, although it will still require on-site implementation and services. It’s the same in terms of product, services, training, but faster and easier to deploy.

Why would a customer buy from Sam’s? Do they save any money? Can they choose a no-services option?

Wal-Mart used its Sam’s Club division because it has a lot of small business customers as corporate members. They buy ongoing stuff every month, not just simple things like gloves and bandages, but have a corporate account and buy copiers, payroll software, etc. They don’t have to go into Sam’s. You call a corporate number, get an assigned representative, talk to them about what you need, and the item is shipped.

eCW salespeople will still show the product and talk to the customer. There are packages we want to give them that are pre-configured. The customer will not pick blindly – they will still consult with an eCW person.

Will Wal-Mart do its own advertising and marketing?

There will definitely be a significant campaign. They have 200,000 healthcare professionals today as members, mostly as doctors.

Any projections on volumes?

I have to keep that confidential, but there was a lot of planning on the eCW side. Investments have increased, made the company even more ready. This can have a significant impact on how physicians look at, evaluate, and purchase EMRs.

We would like to see taking it away from being a niche sales process, where sometimes we confuse the customer, to make it a very streamlined process so that a customer can make an educated decision. They know how many days to go live, how many days training, cost, etc. eCW does 30 Webinars every week that every customer has access to with a live attendant and all Sam’s members will be able to avail themselves of that.

We believe we are the largest SaaS EMR in the country with 4,000 physicians. If we include hospital customers hosting affiliated physicians and RHIOs, that’s another 4,000. That’s 8,000 today of our 25,000 physicians. We’re trying to leverage that scale to make it easier and cheaper to deploy.

Do you anticipate any product changes?

For primary care, we spent two years working with New York City. We put into the product all the content needed to run a primary care practice – templates, order sets, clinical decision support. That is years of content that we jointly developed. That is all pre-packaged with the product – it’s not just the software any more. On the specialty care, we have about 50 specialty databases.

All of that will be available pre-configured when they sign up. When the trainer shows up, all the content will be there and if we want to change it, we can change it together. We will go live with a comprehensive data repository with clinical decision support at no extra cost for the content.

A primary care doctor can go live with the system as it is, with rich content.

What does this to do the competitive landscape?

We’ve always taken tremendous pride on our leadership on price and functionality. 97% of eCW customers surveyed said their total costs met their expectations when they bought and implemented eCW. 93% of physicians said the EMR met or exceeded expectations. I still have to worry about the 7% and I lose sleep about it more than I take advantage of the 93%, but if a package with those numbers is readily available, people will ask the question: if I’m able to get a comprehensive product that people are happy with at this price point with content and support, why should I spend more?

Price visibility will be black and white. No longer will you see those quotes saying an EMR will cost $300,000. You will see more informed questions, pricing pressure, and frankly, higher expectations if content is provided. I don’t want to take six months to implement PM and another six months for an EMR.

This is a unified product we’re offering, by the way, both EMR and PM. We’re offering five days of implementation on site with the Sam’s Club package and they can buy more for $750 a day plus travel, but our track record is that we can do it in five days.

What are the benefits to eClinicalWorks?

There are many benefits. We want to be a company with 100,000 physicians using our product and 100 million patients whose lives are positively affected by it. There’s a lot more work to be done, but this platform gives us more opportunity.

Intelligent Healthcare Information Integration 3/11/09

Step 2 of the “Official Grunt-in-the-Trenches Complete U.S. Healthcare System Overhaul and National Health Information Network in Five Easy Steps Disruptive Innovation Package”

EHR? PHR? Phooey! How about an IHR?

I know, I know. I’m out of step with my previously stated agenda. I was next going to discuss how we can achieve two thirds of the NHIN by 2010, but, after some inquiries I received and after Mark Anderson’s recent superb article, “Beware, The ICE Age is Coming,” I felt it would now flow more gracefully directing attention toward the foundation upon which we can achieve that near 70% NHIN integration.

First, a disclaimer or two:

1) Some of my favorite people are EHR vendors/developers/marketers/implementers/salesfolk. I enjoy and respect them and what they do immensely.
2) I love my EHR (usually.)
3) Mark Anderson and I, along with several other great folks, have worked together on a few of these ideas for some time now.
4) As yet, there are no financial entanglements which need disclosed. (Damn!)

Now, on with the show…

Unfortunately, the tremendous advantages of a capitalistic system in inspiring new innovation and diversity of product development has given us 3-400 EHRs, any one of which has very little ability to communicate directly with any one of the others. Then, of course, there are the multiple silos being created via RHIOs, HIEs, the old CHINs, etc. Diversity of offerings has led us away from, not toward, the NHIN. The complexity and sheer volume of offerings is intimidating even for seasoned geeks, no less the everyday doc who has trouble with a DVR. Few of the mass required to reach the proverbial tipping point for EHR adoption see it as even being a possibility in their career lifetimes. And, so far, I can’t say I blame them.

To reach the masses, we should be listening to their concerns. I wonder sometimes how many EHR developers actually bother to ask a non-techie-oriented consultant to review their work. If the only folks you ask about product development are those who already “get it,” how do design to entice those who are yet to? I doubt Apple would have survived if they hadn’t seriously taken “Joe Sixpack” into account.

So, as the medical “Joes” have rarely been consulted, is it any wonder most of them have had little, if any, interest in adopting EHRs – especially when what they are promised includes a major interruption in their workaday lives. Changing workflows is a horrendous undertaking, requiring enormous time, energies, and, often, income reduction, at least for a time. There are no “plug-n-play” systems, no turn-it-on-and-do-what-you-already-do EHR wonders. Most current offerings require an enormous effort, hence the prerequisite need for physician champions to cheerlead, coax, and cajole cohorts into the commitment.

I don’t think the majority of my medical colleagues should be treated as cattle, herded, prodded, and driven toward the auction house. (OK, maybe a few deserve that.) But, physicians, it is true, are generally not pioneers. The majority do not blaze trails. They do not lead movements. But, the tremendous attribute which can generally be stated about most physicians is that they respond to need. That’s why many, if not most, became health care providers in the first place. So why is it that this very basic truism has been so glaringly ignored by the world of electronic medical record developers?

If physicians, by their basic nature, respond to need, doesn’t it make ultimate sense to develop a motivational tool that engages this semi-Maslovian drive to entice them into a desire for EHR adoption rather than continuing to “push mules?”

If we’re to stop pushing mules, we must employ strategies that entice – i.e., carrots. We must avoid threatening or intimidating change, as change in and of itself is often frightening. We must utilize tools already familiar, comfortable. We must identify true needs and design strategies to both meet them and to take advantage of them in generating “adoption drive.”

This same argument plays equally well when discussing PHR adoption by the general public. The masses have not swarmed to their use. Why? I believe it is because, just as with EHR design, we have neglected to consider some basic human motivations. Consider the fact that Facebook reached 50 million users in 1/20th the time it took television to do the same. Why? It used a tool which many already owned, with which they had familiarity, AND it met several underlying needs including the desire to interact with others while giving users a little ego boost having a little “Look At Me, World” home on the Web. Basic human motivations: we need to engage them.

To address these oversights and to “stop pushing mules,” I suggest we consider a different approach to healthcare information integration, not focusing upon the technology aspect (very Web 2.0-ey) but rather spotlighting the needs, the use of currently proven tools, and the natural human motivations we can engage to help inspire adoption and continued use.

Thus, the “Grunt-in-the-Trenches Beyond EHR/PHR Grand Healthcare Digitization Project What Ifs:”

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What if…we start with a system designed for the end user, not the giant hospital or RHIO, but for that single grunt in the field so that he or she can provide the services he or she provides in the manner most comfortable for him or her with an electronic interface he or she can enjoy and adapt for his or her unique needs? (Big systems that attempt doing everything for everyone often have poor usability when they trickle down to us grunts.)

What if…we took that end user-friendly provider system, included a general populace-friendly tie in, and pivoted this patient-centered tool around an entire small community and its associated community hospital including everyone including doctors, hospital, EMS, home health, hospice, schools, long term care facilities, police, sheriff, fire departments, emergency management agencies, health departments, employers, and the general public – everyone who might have need for some small piece of healthcare data – utilizing the entire community as a multifaceted motivational driver for adoption? (Patient-centered, but community driven as communities drive individuals. Consider mob mentality, Facebook, soccer crowds.)

What if…we make the wild assumption that sharing health data among providers is no different electronically than it is “paperly,” that what a provider can get now through laborious effort, fax machine, and telephone is essentially the same – only much, much slower? (I know a company who says they can tie legacy systems into a new, integrated system so that even current end users don’t need to buy a new EHR or PHR to participate, identity management is enabled, and security is priority.)

What if…we use an open system (open, not unsecured) that doesn’t create silos and we help health systems and providers understand that patient health data is not “owned” by anyone except the patient, that sharing that info is not counterproductive to corporate profits but rather contributive once all are duly linked? (Healthcare giants must give up the notion that sharing a person’s health data is akin to a traitorous CIA leak. I can’t imagine an auto shop refusing to share someone’s car repair history.)

What if…we design the roll out to the community with something like Java applets (compatible with most cell phones and computers) using push/pull technology to acquire information and participation in small sips, instead of asking folks to drink from the fire hose most PHRs now do? (Of course we’ll use computers, but, cripes, American Idol uses cell phone data collection every week! As there are over 4 billion registered cell phones in use around the world today, doesn’t it make sense to use a tool people already have and one with which they are not intimidated?)

What if…we created several jobs within each community specifically to promote, educate, and assist end users in an ongoing fashion, instead of the two-to-a-few weeks training currently the industry norm? (If the entire community was “going live,” the need for support would justify and, indeed, require local help. Plus, who’d bitch about creating thousands of new jobs these days? FYI – there are some 2,000 such small communities and associated community hospitals across the U.S.)

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Mark Anderson laid out quite nicely some of the system requirements and benefits in more detail in his “ICE Age” article. While he limits his discussion to the integration of doctors and hospitals, something he has promoted for some time, here the discussion is for a COMPLETE community system, an entity for which the current lexicon has no definition. We’ve coined the process as Community Healthcare Integration (CHI) which achieves the Integrated Healthcare Community (IHC) utilizing the Integrated Health Record (IHR) – via each community’s own non-profit, by the way. See: http://worldchi.com.

To be clear, the IHR does not negate nor minimize any current EHR or PHR product. Rather, it is an overriding integration of that which currently exists into what I believe is a more accurate reflection of reality. We need specialty EHRs and PHRs; they are operationally helpful and discrete. But, personal health data is not separate and distinct from that data which a medical provider uses. The emphasis upon these two terms promotes a psychological barrier between providers and the general public. The last thing we need is for the application of technology to increase the gap and diminish the trust between providers and the public. There are far too many silos in healthcare already; the IHR model is designed to help eliminate separatization and promote integration. (Can you hear the NHIN segue?)

Still to come:

Step (now) 3: Two Thirds of the NHIN by 2010 (Yes, we will discuss funding & sustainability)
Step (now) 4: Equalizing the Playing Field (“Open” is not a Four Letter Word)
Step (still) 5: Verdant Health

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.

News 3/10/09

A pediatric nurse practitioner provides first-hand details about her practice’s selection and implementation of Epic Ambulatory.

NextGen Healthcare Information Systems announces that the national physician group practice MEDNAX, Inc. is expanding its use of NextGen’s products to include the Enterprise Practice Management solution. Pediatrix Medical Group, now a part of MEDNAX, has been utilizing the NextGen EHR for its office-based practices since 2001.

Physicians at Carilion Clinic (VA) utilize their EMR to develop a disease registry for asthma patients, estimating that it will reduce costs 10% and will help monitor medication compliance, ED visits, and vaccinations.

An Archives of Internal Medicine article says that physicians ignore 90% of the warnings generated by e-prescribing systems. "The systems and the computers that are supposed to make [physicians’] lives better are actually torturing them," the article’s co-author said, adding that a third of the alerts were scientifically unsound or not clinically useful.

CPU Medical Management Systems partners with Gateway EDI to expand its electronic claim processing capabilities. CPU serves over 10,000 physicians.

EMR-generated colonoscopy reminders work better when sent directly to patients instead of reminding their doctor, a new study finds.

A new doctor-run wiki is up and running. The Medpedia Project is a free online medical information platform, written and maintained by health experts and founded by the Harvard, Stanford and University of Michigan schools of medicine, along with the Berkeley School of Public Health. The tool is available to consumers as well as physicians.

Family Health Care Clinic (MS) becomes one of the country’s first health facilities to receive a chunk of taxpayers’ money since the passage of the economic stimulus bill. The $1.3 million government grant that will be used to open three clinics in an under-served area of rural Mississippi, creating an estimated 70 jobs including 30 full-time positions. In the mean time, Portneuf Medical Center (ID) has applied for nearly $4 million to continue work on the Telemedicine Network, which really sounds like an HIE and not telemedicine.

Nearly 300 student members of the AMA participate in a Lobby Day at Capitol Hill to urge Congress to protect patient access to care, ask for medical school debt relief, and to stop Medicare payment cuts.

An Arkansas doctor who had been sanctioned by the state medical board is arrested after over 100 fully automatic weapons, a canister of grenades, and two grenade launchers were found on his property. Authorities say the arrest is not tied to the investigation of last month’s car bombing that wounded the chairman of the state’s medical board.

Worcester Polytechnic Institute launches a three-year study of four different HIT systems in various stages in installation. Two of the organizations are in the US, one is in Canada, and the other in Israel. Using a $750,000 grant, the study will investigate how implementing HIT systems in primary care impacts providers, their patients, and the operations of the healthcare delivery systems. Findings will be used to develop new insights and best practices for future HIT implementations.

The  100+ physician Virtua Medical Group (NJ) selects GE Centricity Business Advantage for revenue cycle management.

An LA Times columnist says America’s Health Insurance Plans, which claims to now support universal healthcare, is really just asking for the same old stuff: to have the government pay for treating the sickest patients, to cut pay deeply to doctors and hospitals, and to be able to offer cheap, low-benefit policies without having its premiums regulated. "The industry talks a good game about marching for reform side by side with all healthcare stakeholders — patients, drug manufacturers, doctors and hospitals. Ignagni says her members will ‘come to the table with real proposals and solutions’ rather than ‘the old-fashioned playbook of ads and 30,000-feet campaigns.’ Veterans of earlier healthcare battles justly wonder if the industry is merely trying to get in front of the parade, the better to lead it into a dead end. "

Many groups and individuals have been calling for CCHIT to evaluate more than interoperability, having it rate functionality and usability in addition to what it does now (sometimes straying far off the interoperability track and getting into those areas anyway). Should the government be in the business of rating and comparing commercial products at more than a pass-fail level of granularity? And if so, should CCHIT (and its previous HIMSS connections) be the one doing it?

Would an EMR have helped here? The Iowa Board of Medicine cites a physician for failing to maintain "timely, accurate, and complete" medical records. She agrees to pay a $1,000 fine and stop practicing medicine while she attempts to get her records current. 

An EMR would probably have impacted the outcome of this case. A Kansas cardiologist and his practice agree to pay $1.3 million to settle Medicare fraud claims. The Justice Department contends the physician submitted claims for services not rendered or without proper documentation. The attorney claims the issue was all Medicare’s interpretation of the documentation rules, which required that certain portions of the records to be in the doctor’s own hand, rather than dictated by the doctor or written by a nurse. Which, frankly makes no sense at all because many, many doctors use scribes and/or dictate the whole chart. This happens to be the doctor’s second Medicare settlement. The first was for $1.5 million in 2000 after the doctor was charged with over-billing Medicare.

E-mail Inga.
E-mail Mr. HIStalk.

Mark Anderson 3/7/09

Beware, the ICE Age Is Coming

The EHR industry has been claiming great implementation successes for the past five years. When you ask the various vendors, “How many successful EHR implementations have you done?" the answer would amaze even the most skeptical person– however, in the wrong way.

Based on data obtained in the 2008 AC Group survey, the top 100 EHR vendors claim they have more than 300,000 physicians using an EHR today. This is almost too good to believe — and for good reason. According to a New England Journal of Medicine article dated July 3, 2008[1], “only 4% of physicians reported having an extensive, fully functional electronic records system, and 13% reported having a basic system”.

This means that after 20 years of EHR adoption, less than 30,000 providers are using the full capability of an EHR, and an additional 90,000 are using partial EHR. So what does this mean for the entire medical community?

Basically, the EHR industry has FAILED miserably. The main question everyone should be asking is, “Why after 20+ years do we only have 4% of physicians using fully operational EHRs?” The answer is usually, “Cost is a factor”.

However, we do not believe cost is really the factor for low adoption. In fact, some EHR products are provided free of charge or at a highly subsidized rate. Even these products have not been implemented in masses.

So what is the real problem with EHR adoption? The main reason we hear is that EHRs slow the physician down. One reason: there is no information in the product when it goes live.

To help resolve this issue, AC Group has coined a new term, Integrated Community EHRs (ICE). ICE products are designed for community systems, including hospitals, MSOs, and IPAs where there is a desire to create a community-integrated patient record no matter where the patient is treated. These products may have full EHR or EMR-Lite functionality.

A true ICE product must provide and maintain a community health record via a community clinical and demographic data exchange.  Advanced functionality includes reporting and tracking of orders, results, e-Rx, allergies, and problem lists, among others. The product must provide a community master patient index based on numerous inputs, including hospitals, health plans, and numerous physician practice management systems.

ICE products have the abilitye  into interface with multiple EHR vendors following the national CDA standard. With changes in the Stark laws, hospitals and other community initiatives are interested in viewing ICE applications.

Under a community model, ICE product allows multiple practices to share information regarding the patient, even though the practices may have different EHR products. To insure an effective community EHR, the product of choice must have the following capabilities:

• Community master patient index (MPI) for retrieving patient and insurance demographics.
• One interface between all third-party companies (LabCorp, Quest, PACS, hospitals) while allowing the sharing of interface costs between all practices.
• Patient demographics information where an address change can update each practice’s database.
• Patient insurance information shared between all practice’s databases.
• Patient family, social and medical history can be updated by one provider or by the patient. The information can be updated as discrete data into a practice’s EHR with one click.
• Potential for centralized billing and accounts receivable with multiple tax IDs.
• Reporting as individual databases and the ability to report clinical data over the entire community.
• Referral tracking between multiple tax IDs.
• Community patient portal, community physician portal, and community registry reporting.
• Allows practice to leave the community and remove their database without adversely affecting the community EHR repository.

Benefits of an ICE Age strategy:

• Data is entered once and can populate multiple databases.
• The patient has complete control over disseminating data following HIPAA rules.
• Duplicate data entry is reduced by 92%.
• Overall data entry time is reduced by 74%.
• Clinical testing is reduced by 19%.
• Referral tracking activities are reduced by 32%.
• Uncompensated ER costs are reduced by as much as $500,000 for every 20,000 emergency room visits. A study conducted by AC Group on 3,120 ER visits determined that if clinical data was available to the ER physician at the time of treatment, the ED physician could properly treat the patient faster and with fewer tests. Patient time in the ED was decreased by 26%. Test costs were reduced by 31%.

In summary, to enhance EHR adoption, we need to move to a new model where clinical data is shared between physicians who are treating the same patient. With community governance and security rules and regulations, an Integrated Community EHR can enhance the use of EHRs and finally drive true ROI.

[1] – N Engl J Med 2008:349:50-60

Mark Anderson is CEO and healthcare IT futurist with AC Group, Inc.

Mike Gleason 3/5/09

Moving Toward Specialty-Specific EMRs

I’ve noticed a trend over the past few years in EMR/EHRs. I’m seeing a lot of EMR to EMR conversions where the practice is not happy with their all-in-one EMR. The existing EMR is often their first one and they are looking to convert over to a more specialty-specific EMR/EHR. More often, practices are converting to their third EMR. One wonders how these practices, many containing 10 doctors or more, can continue to make costly EMR replacements.

Common reasons for the switch? In speaking with the practice administrators, consultants, and providers, I hear some pretty consistent thoughts. The practice needs better specialty content, relevant workflow, faster documentation speed, and a system designed or tailored to their specialty. A growing trend in healthcare practices over the past few years has been mergers between large, specialty-specific practices. These practices have tough decisions over which PM and EMR they should keep. Usually one group is forced to adopt the EMR and PM of the majority (often kicking and screaming).

I thought it might be interesting to bring this up to readers and see if they are experiencing this as well.

Content

It seems that many of the generic, all-in-one, or multi-specialty (take your pick of labels) EMRs are not able to provide rich enough content for a specialist. The specialties I see most often struggling with customization of content in a generic EMR are urology, gastroenterology, neurosurgery, ENT, dermatology, general surgery, and plastic surgery.

These are just some of the specialties getting the short end of the stick in terms of standard templates and content in many of the all-in-one EHRs. The content in these EHRs heavily emphasize family medicine, internal medicine, pediatrics, and gynecology.

Most EMR/EHR vendors are in a mad dash to provide a wealth of content to prevent client attrition as well as add new customers to their client pool. The mistake that vendors often make is that they forget to run this content past the physicians, nurse practitioners and physician’s assistants using the software 40 hours a week or more. This content dash may be for naught if the providers are not included in the design and QA process.

There is a fine art to creating great content. It often involves a lot of tweaking and refining and testing. Content testing is most effective when done in an actual clinic setting, where users experience off-the-wall combinations of issues and can provide instant feedback on speed and effectiveness.

During the implementation process, a practice is asked what their top 10, 20, or 50 diagnosis codes may be. However, the list they provide rarely matches the mix of actual patient chief complaints during go-live. That’s why testing the customization on live charts prior to go-live is so critical. If the implementation process can focus on the 80% of the content they see daily, the other 20% can get created post go-live. After the go-live, physicians usually have a better idea of what additional customization is needed.

In order to get content to the level that specialists require, vendors have historically placed the burden of content creation on the practice. The creation work often falls on physicians, who have little time to learn customization, much less do the actual customization work. In other words, vendors measure the success of their software based on how successfully THEIR CLIENTS can learn how to customize THEIR software.

I’m reminded of a struggling physician who had completed three days of customization training. He relayed his frustrations to me this way. “I feel like I bought a Bentley, the nicest Bentley on the market. Unfortunately it has come with complete assembly required and the instructions are all in Chinese. I wonder if I’ll ever get to drive it?”

How can we let the success of our product depend on how well a physician can learn to customize it? Often, practices will not customize or improve their systems much beyond what they had at their initial go-live. They find a way to get by, which often includes scanning handwritten notes or dictation. Many vendors now offer customization for the client, but these services are billable to the practice.

I think practices can benefit from narrowing the field during their EMR search and focus on EMRs that cater to their specialty. Content delivered by specialty-specific EMR vendors can allow for faster adoption because the workflows make better sense and are more familiar to the clinical staff.

Workflow

“This EMR workflow does not fit our office.”

“Our office has to adjust to the EMR workflow.”

“We don’t schedule like a family practice. We see patients every 10 minutes and may see 50 patients in a day, two or three days a week.”

These are common complaints that can be heard from specialists trying to cram a generic EMR in their office. If you deal with urine dips all day long, you need a fast way to enter results. If you have specific lab devices, you need an efficient interface with your EMR. If both the doctor and nurse work on the same patient encounter at the same time, they need to have dual entry capabilities in the EMR.

Many specialists have to fax letters and H&P reports to multiple providers for one patient. They need easy to use tools to indicate which items (the office note, the lab data, imaging reports, etc.) need to go to the primary care provider and which need to go to other treating providers. If an EMR can only generate one H&P or referral letter at a time and can only fax to one office or provider at once, you are not going to make the grade in a specialist’s office.

A specialist’s office may follow unique workflows that can’t be duplicated in some EMRs. For example, some EMRs do not allow a nurse to order labs on behalf of the physician, or allow lab results to forward automatically to the nurse. Often the nurse is the one monitoring the lab and e-prescribing process, then forwarding the record to the physician for sign-off.

Specialists often do not follow a typical SOAP-type flow in the patient encounter. You may need to order and result a lab prior to the physician seeing the patient. Office procedures such as EKGs or breathing treatments may need to be completed prior to the physician seeing the patient for the first time.

Specialty offices also need a greater focus on their specific body system in physical exam. A generic EMR often can’t provide that detail without massive and complex customization. Many specialists need to include lab data as well as note what specific data review process was completed prior to completing an assessment and plan section. Generic EMRs often lack this ability.

Speed

I was shocked when I first encountered a specialty office where they see 50 patients in less than a six-hour shift. A generic EMR rarely has the capability to effectively complete more than 25 to 35 office visits in a day with a very adept family medicine provider running the keyboard. Place one of these EMRs in the hands of a specialist and you can have a recipe for disaster. If the EMR does not have the generic content turned off and the specialist’s content customized with their specific phrases, the software may get tossed back in your face.

Many EMR implementation consultants do not know how to customize their vendor’s EMR for speed and efficiency. There is a fine art to making content that is complete, quick to document, and easy enough for a beginner to comprehend and use on a daily load of patients.

Many EMRs lack the ability to share templates between practices. Specialists may need the ability to import different types of formats, such as images, pictures, and drawings. This can be a bottleneck if the EMR vendor does not work with different document formats.

Tailored for my specialty

Given enough time, you can customize great HPIs, assessment and plan order sets, physical exam templates, nurse lists, history lists, etc. Many practices never get to this higher level of customization. A specialist will never achieve success in a generic EMR because they can’t afford to put in the hours required to customize the product to suit their needs. They can’t take the hit to their revenue or reduce their patient load. Many have minimal staff and lack the support staff to work on the back loading of data, scanning, or customizing.

Specialists have a very focused data set for patient history that is often hard to understand when you are trying to use a generic history form to gather data. Most practices fail to take the opportunity to change the forms used to gather information from patients, as well as tailor the history lists to their specific needs. When the form comes back across the counter or data is entered in the kiosk or Web site by from the patient, does it make sense? Is it even usable in the specialist’s EMR?

I guess the question to ask is, “Are generic EMRs doing more harm than good when implemented in a specialists office?" I’m interested in hearing from the practices. 

Mike Gleason is a 25-year veteran of the HIT industry with expertise in sales, support, and implementation of clinical and financial systems.