Archive for the tag 'Adoption'

The Three Types of Organizations that Need New EHRs

The era of electronic health records has arrived and opportunities for innovative uses of data are plentiful for providers and vendors alike. Fueled by financial incentives from the government as well as meaningful use requirements, organizations that best position their data to help providers deliver patient centered care will flourish. Physician organizations are also becoming larger through growth, acquisitions, and mergers. These growth milestones provide organizations opportunities to reflect on the capabilities of their current medical record system in order to decide if their current system will keep them competitive in the future. These are the three types of organizations that will be purchasing a new Electronic Health Record (EHR) system in 2013.

The New EHR Adopter

  Buying a new EHR is not cheap which may explain why many smaller physician practices have held out on the investment as long as they could. Only around 20% of providers are attesting to Meaningful Use in the US. However, government mandates and incentives are forcing providers to overcome their resistance to EHRs. While larger practices initially lead the charge into the digital record world, SK&A has shown that small physician practices are growing their EHR adoption rates faster than larger physician organizations over the past few years. According to KLAS, many of the smaller provider organizations are using cheaper vendors such as athenahealth, eClinicalWorks, and Practice Fusion which have been enjoying their recent growth.

While there are still some larger organizations that need to adopt an electronic medical record system, the majority of the New EHR Adopters over the next year will continue to be small provider organizations.

The Acquired Converter

While the smaller practices are still adopting EHRs for the first time, larger practices, which boast an adoption rate over 78%, are experiencing a different phenomenon. Rather than leading the pack in adoption rate growth, they have been increasingly switching vendors! One reason for this is due to consolidation that is occurring throughout the healthcare system. Federal incentives for the development of Accountable Care Organizations are driving larger physician groups and hospital systems to acquire the small practices in their local area. According to the American Family Practice Journal, the only non-government EHRs that are predominantly used by these large physician practices (>50 providers) are Allscripts Enterprise, EpicCare Ambulatory, Cerner Millenium Powerchart, and InteGreat EHR.


As acquisitions and mergers continue, organizations will have an increasing need to be able to both communicate clinical information between existing applications as well as convert data from one vendor’s EHR to another. While the messaging standards such as HL7 and CDA are easing the integration pain, conversions are becoming increasingly difficult for organizations. Many smaller vendors have data structures that are easy to understand, however they often do not store data discretely making conversions a nightmare. Larger vendors have the benefit of storing data in a more logical way, however the sheer volume of data combined with the lack of support during the conversion process makes transitioning between EHRs extremely difficult. While it is understandable for a vendor to dissuade groups from moving off their software, some providers are beginning to feel like their data is being held hostage!

The Disgruntled Replacer

The last purchaser archetype for 2013 is for the small, but growing minority of providers that are dissatisfied with their EHR system. The CDC reported that a vocal 15% of all providers reporting to them are dissatisfied with their EHR choice. Some of these providers chose a vendor based on price and have outgrown their current EHR’s capabilities, while others chose an EHR that was not a good fit for their organization. These providers often have specific needs in their organization and need extra support from the vendors in order to meet the incentive goals that drove them to purchase their EHR. They need to integrate with local Healthcare Information Exchanges, report on quality metrics, report on financial incentives, and make adjustments to the EHR to fit the way they practice medicine. Providers don’t need to know how the software works; they just need to know how to use it effectively. However, IT specialists know that the quality of the data in the EHR is only as good as the quality of the data put into it by providers. Without the proper workflow training and support from the vendors on how to make the EHR work for a provider, organizations will have a difficult time just using the EHR and never realize the benefits of electronic data management. However, according to the American Association of Family Practice Management, 56% of primary care providers are not satisfied with EHR vendor support and training. This may be why the percentage of EHR sales to physician organizations that already had some form of EHR rose from 30% in 2011 to 50% in 2012 and is showing no sign of slowing down.

A Look Ahead

KLAS recently reported that vendors such as athenahealth, eClinicalWorks, Epic, and Greenway Medical Technologies are gaining market share while the traditional ambulatory EHR vendors such as Allscripts, Cerner, GE, NextGen, and McKesson are struggling to continue the explosive growth they saw over the previous 10 years. While no one vendor is the best for every organization, it is clear that the struggling vendors need to focus on creating better products and supporting them for their customers. With Cerner and McKesson in the lead in revenue and Epic and Allscripts in lead with the most implementations in the ambulatory space, the big players have an opportunity to learn from their mistakes. However, the ambulatory market is still open for any vendor to improve the EHR data structures, design more user friendly interfaces, design products specifically for specialty practices, and utilize technologies from other tech sectors such as phone apps. EHR implementations will continue to be a significant investment for organizations and it will be exciting to see the improvements to EHRs in 2013.

Meaningful Use Attestation: EHR Vendor Market Share & Anticipated Consolidation

As 2012 came to an end and we wrapped up another eventful year here at Galen Healthcare Solutions, I did what I like to do as holiday songs filled the office – write a blog on interesting articles I finally got the chance to catch up on. The theme for the past year was Meaningful Use, of course, and Conor Green, Vice President of Triple Tree, a consulting firm focusing on healthcare compliance, payment integrity, and provider-payer convergence among other things, wrote a great article called “Numbers Don’t Lie – The EHR Market Must Consolidate” in August 2012 and I think is worth looking at again.

From 2011 through May of 2012, 2400 hospitals and 110,000 eligible providers completed the attestation process and received 5.7 billion dollars in the form of incentive payments for demonstrating meaningful use of their electronic health record systems. This accounts for nearly 50% of the hospitals and 20% of providers nationally. Attestation, by definition, is the process in which practitioners verify that they have used EHR in a manner that is congruent with the incentive program’s criteria.  Green mentions in his article that there is a discrepancy between the CMS press release numbers and the data released by the database, but finds 77,000 attestations were initiated between 2011 and May of 2012.

Green has some great charts that display the information in a valuable light. Of the reported 405 separate EHR vendors (550 vendors are listed on CMS’s Certified Healthcare IT List), approximately 336 of them offer an ambulatory product. As Green astutely points out, this signifies that over 200 vendors are without one provider that has successfully attested and qualified for MU incentive payments.

Attesting Provider Marketshare By EHR Vendor

Attesting Provider Marketshare By EHR Vendor (InPatient)

Looking at the relatively large number of vendors, a concentration of users attesting is found within the top vendors. Within the inpatient setting this trend is even more obvious, as the top 6 vendors represent 75% of the attesting population. On the ambulatory side, of 336 vendors, the top 15 represent 75% of the providers population attesting. While not that surprising, that fact is somewhat concerning. What about the other 25% of the provider population that utilizes the other 95% of ambulatory vendors? One might infer this data implies that 95% of the vendors are offering a product that is not serving 25% of the provider population well going into the future. With that said, this significant portion of the provider population are arguably subject to a higher risk of having to adopt a new EHR system and/or undergo a conversion as the industry consolidates.

Within the ambulatory market, Epic (which does not market an ambulatory EHR product) has a considerable lead among the top vendors in that particular sector. What does this mean? That the likelihood of hospitals acquiring or having some controlling role within the ambulatory setting is increasing. Green references “Becker’s Hospital Review” for a snapshot of this trend. Although there are a multitude of possible factors that are contributing to this trend, in the end, it all boils down to money.  The cost of purchasing, implementing, and maintaining an EHR and the efficiencies created by utilizing existing infrastructures and staff competencies (or lack-thereof) increases the value of a hospital-clinic relationship in regards to hospital hosted ambulatory EHR systems.

Green points out an interesting question with his example of Athenahealth & their Athenaclinical user base.  The vendor claims that of their 6000+ providers, approximately 2050 of them have successfully attested to date.  This begs the questions, “Why?” and “What about the other 3-4 thousand users?” Be assured, there are a variety of underlying causes for this short fall, but with the larger client’s I have had the opportunity to work with, there is one glaringly obvious reason – staffing. Overcoming the sheer obstacle of the work effort required to complete an initiative like adopting any EHR and being MU compliant has effectively excluded a large number of these practices and providers from attestation.

The resources needed to build a system that accommodates every specialty, individual clinic sites and subsequent providers, is substantial and in many cases unworkable for these clients, without support from vendors and third party groups. Add the fact that a majority of large scale EHR rollouts take significant amounts of time (as they onboard new providers and sites, supply adequate training, go-live support, application & IT support), not to mention staying current with the continuous software updates and policy changes in attempt to conform to MU criterion and you can quickly see how large of an internal Human Resources effort is required. But, I digress.

Green brings us back on topic by pointing out that one of the goals of MU is to improve interoperability, specifically, “A new national infrastructure to support deployment & beneficial use of EHRs…” Having upward of 600 vendors that offer thousands of products does not seem like a great environment to foster the success of the incentive program’s goal. Instead, it is the product of a demand (stimulated or not) being met by suppliers (capable or not) that are trying to get a “slice of the pie” of the EHR industry.

As Green states in reference to the EHR vendor market, “it certainly seems ripe for consolidation…” and I would have to agree.  Taking into consideration the hospital-clinic alignment trend, payer-provider alignment changes, and the fact that the incentive monies are limited and are quickly expiring and the future appears clear. From a business perspective, all of these factors indicate a maturing market, affected by a high number of entrants, vendors, and products that will result in consumers’ becoming more price sensitive as incentive monies that might have been used to subsidize the cost of EHR implementation become scarcer. With all that said, the market forecast looks like consolidation of EHR vendors and a downward pressure on prices are inevitable. This indicates there may be more adoption and conversion in the foreseeable future as the “best” EHR vendors compete for market share.

Day 2: Health Information Technology – Creating Jobs, Reducing Costs, & Improving Quality – A National Conference Hosted by Governor Deval Patrick

Last Friday, I attended Governor Deval Patrick’s HIT conference in Boston and present my own musings and takeaways from day 2 of the conference. Be sure to check out Dr. John Halamka’s reactions from last Thursday morning’s CEO summit at the Govenor’s HIT Conference.

Keynote from the Surgeon General – Vice Admiral Regina M. Benjamin

  • She covered how Hurricane Katrina affected her community in Alabama and the fact that due to the natural disaster, they were reliant on pharmacy chains to provide a record of what medicine the patients were taking.
  • She also touched on a story of how members of her clinic were drying out the patients records after Hurricane Katrina and after they had them completely dried; a fire burned the entire clinic down. This brings to light the need for disaster recovery and collocation in some circumstances. Galen Healthcare Solutions proudly offer a downtime solution in its VitalCenter product.
  • After the fire, Bentley college students came down to assist and one of those classes contacted the president of e-ClinicalWorks and convinced him to donate the EHR – integrated with both labs & referrals
  • She stressed that prevention is the foundation to the National health System and as such we should be incentivizing prevention.
  • She also mentioned how the EHR played a major role in prevention of errors

Getting Clarity – Developing Effective Health IT Policies and Standards

  • Need to integrate claims and clinical data to provide total model for exchange
  • 15 cents of every dollar in healthcare goes to administrative overhead
  • Two key issues for data exchange – identity and consent
  • Public Health entities currently receive data, however not every public health entity has the infrastructure to receive data
  • How do we pull quality measures out of unstructured text?
    • Analogy of querying for alcoholics, but free text match is returned about using alcohol to swab skin before applying needle.
  • The tough part of concerning clinical quality measures is the balance of structured and unstructured data
  • Healthcare delivery is complex in that there is heavy fragmentation – 80% are solo or two physician practices
  • Dr. John Halamka mentioned that we are the stewards of our own data and architecturally that is the design of the system

Jobs, Jobs, Jobs – Health IT, Business Opportunities, and Job Creation

  • Healthcare workers do not have not enough IT in their educational curriculum
  • Howard Messing, the President of Meditech mentioned that in Massachusetts in particular the cost of living is a barrier – Meditech actually has commuters from Atlanta.
  • Girish Kumar Navani, CEO of e-ClinicalWorks indicated that they currently employ greater than 1000.
    • He anticipates hiring 500 new workers over the next 2 years for programming and business analyst positions
    • He also mentioned the analogy of the electrical socket – broadband network need to be as irreplaceable in physician office as the electrical socket.
    • He believes there is a need for a  new type of worker, the knowledge worker, who understands workflow and is able to analyze and make better decisions about population health
  • Richard Reese, Executive Charmain of the Board, Iron Mountain, anticipates helping hospitals clean up paper mess.
    • He mentioned non-compliance in healthcare IT to storage and backup standards
    • Lesson in compliance can be drawn from Wall Street years ago and that healthcare organizations must design for workflow, but compliance as well
  • Brad Waugh, President & CEO at Navinet, indicated that the network his company providers connects payers and providers, saving $800 million per year.
    • They currently require Microsoft .NET certified engineers and have over 30 openings
    • He indicated that the educational system must produce the folks needed in healthcare IT and currently it is just not doing so domestically
  • This discussion brought to light a deeper seeded issue in American society in that as a society we are not pushing computer technology anymore as it is no longer the glamorized industry.
  • There is a major need for qualified issues and it is a supply versus demand issue with the roots in education and society.
  • One member of the audience mentioned that the goal of healthcare reform is to eliminate costs and the irony is that in a sense we are creating jobs to eliminate jobs
  • Another member of the audience commented on the arrival of programs for night healthcare professional courses, much like it was the trendy thing to get a night MBA in the 90s
  • Finally the point was made that by the middle of the current decade, we will be facing baby boomers hitting Medicaid and the amount of care they need is incredible. With less dollars, we will need to re-engineer the system and what could come as a result is care rationing

Panel: Successful HIEs – How They Did It and How It Helps

Fallon Clinic HIE

  • Emergency care was the highest reason for HIE usage
  • Some quotes from physicians on the value the HIE provided
    • “Importing the CCD expedited documentation”
    • “Reduced need to ask patients questions”
    • “Expedited verification of medication and allergy list”
    • “Saved time”
    • They estimate phone calls were avoided for 75% of hospitalist and were extremely beneficial for new patient visits
    • They estimate they spent 3 years and $3 million learning and developing “trust” and $1M in building and implementing in the final 2 years
    • Lesson learned:
      • They pre-registered all of their patients in the community (bulk-load) and this helped with performance as they didn’t have to query the state
      • They felt the key to sustainability was to reduce operating expenses
      • Each organization in the HIE was responsible for server maintenance – ends up being $2000/year/organization which represents rounding error in most healthcare IT budgets
      • Key points – earn trust – utilize real-world workflows – value of low cost

Indiana Health Information Exchange

  • Federated data model – 62 hospitals – 3 billion structured results – doubling time of 4 months
  • They meet the providers where they are whether it be delivery of data to the EHR or physicians receiving data as PDF or view into a portal
  • They view sustainability in the sense of funding via offering services
    • work with public health services for syndrome surveillance and track immunizations
    • Their business model for sustainability is such that scale is needed and again they emphasized avoiding grants for operational costs.


  • Their sustainability model is such that their organization provides governance – decide what has value – much as a board of directors would
  • Federated model works better than centralized – more accepted in the marketplace
  • Lessons learn include integrating processes across the enterprise
  • The case of the transfer of information to public health is needed to sustain HIEs as well as the capability to sell other products within the network.

Excuses for not implementing an Imperfect EHR

More structure and planning help to head off excuses and voluntary non-compliance.  One of the more common excuses is finding reasons the system is less than perfect, ignoring the fact that the system is replacing a flawed system in many cases.  I couldn’t count the times I have spent  explaining “flaws” in a system that were really the same flaws that existed in the paper world.

There has to be accountability for non-compliance with expectations.  Metrics have to be in place to track compliance and remediation has to be in place to assist with compliance.  This needs the appropriate chain of command authority and support.

Here are some thought to promote compliance.

Competition – Use individuals competitive spirit to drive compliance.  Publish compliance success stories that prove utilization is possible which naturally spark some competitive spirit in some, which also is aided by the “un-biased” peer being the one that made it work and can use their clinical credibility to persuade.  Physician Champions are often well suited for this because they have a better understanding of the big picture.

Buttons – Take the time to take notice of what the pain points and satisfaction buttons are for the varied audiences.   If you know what these are the message can be tailored to accommodate the differences.

Piloting – Use piloting to work out the kinks.  If you aren’t sure how something is going to play out in a specific situation, play it out with a willing participant or champion to refine the process before rolling it out in mass.

An Alternative to Straight Implementation Milestone Driven Adoption

Mandated functionality use with a Live date without a plan to get there are begging for user adoption failure.   There are few organizations that have the ability to staff “Big Bang implementations.”  Whether big bang or some portions of the functionality, I think having just a live date can be very frustrating for users.  There are several factors coming into play on effective EHR adoption of functionality that are not accounted for in a situation where there is only a Live date and not a plan around what “Live” means.  For instance if we “go-live” on e-prescribing, what does this mean?  Some groups never define what this means and get several flavors of compliance or non-compliance.  What does it mean?  Does it mean that every patient from go-live forward will have a complete EHR medications list or all new prescriptions will be ordered from within the EHR or does it mean that the module is now available for use.   Come up with a fair solution that enables compliance without setting an expectation that is not realistic.

There are variables which vary by practice type or specialty affecting what makes sense for the implementation or adoption of functionality.   For instance, if I see 15 patients a day the expectations could be different than someone who sees 40 patients a day.  Some more variables include the first which I will call “Patient Repeat Value” or PRV a ratio that has to do with how often patients will return for a visit defined by number of visits divided by number of unique patients over a given period of time, and second which I will call “Patient Population Cycle Time” or PCT is the amount of time it takes to cycle through your active patients.

Volume is more obvious so let’s look at PRV.   If a clinician sees 40 patients a day but his PRV is high any pain associated with new functionality that is driven by items that are maintained list such as the various items on the paper face sheet like medications, problems and allergies will be more short term than someone who has a lower PRV that sees the same patient load, because they have a larger population and ergo more lists to maintain.  PRV may not be as relevant in items like electronic noting where it comes down more to practicing and repetitions to become efficient.

Let’s look at PCT as it applies to the first go-live of the EHR.  The best way to explain how PCT comes into play is that it makes every patient’s first visit in the EHR almost like a new patient visit.   We know that visits for New Patients typically take longer and their appointment times typically plan for this.  A logical conclusion from this comparison would be that schedules need to be changed to accommodate these “New to the EHR” patients.  If the PCT is 60 days, like it might be in an Obstetrics office or perhaps even lower in a Nursing Home, it could be practical.  However in Family Medicine it isn’t practical if some of my patients might not come in within 18 months but they are still considered active patients.

Since all practices aren’t created equally with regard to these variables it isn’t realistic to expect the same results from different groups.  Required utilization should be mapped out to accommodate the differences.  Come up with a strategy that allows the practice to step through to full utilization.   Sometimes it is simply something like applying the new functionality to every third “New to the EHR” patient for 60 days and then you’ll have a majority of your visits utilization compliant.  In other situations the logic is broken down by seeing different appointment or patient types initially and then working into the other types as you progress.  The main logic is to come up with steps that are easier to swallow than doing everything different than what was done yesterday.

Worth equal consideration, is a realistic timeframe for supporting an in progress EHR.  We have to coach the users through the implementation, to do more than what they think is possible.  Having an approach just as defined above will serve as the roadmap for the end user to get to some where they have never been.  Having never been there they don’t know what to expect.  Users can’t be allowed to always take the easy way out.  This sometimes involves repetitive reference to the gains and benefits that will be available.  If you don’t get the medication lists and problem lists in for the patients, notes can’t automatically cite from these lists etc.