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HIStalk Interviews Glen Tullman, CEO of Allscripts, 2/5/09

February 5, 2009 Interviews 25 Comments

The recent Allscripts survey basically asked physicians if they would accept free EHR money. Does the overwhelmingly positive answer really mean anything?

gtullman I think it does. What is interesting about the recent survey is how it breaks out. Physicians have said that they would like money – even a small amount of money would create a very substantial stimulus toward not only adoption, but utilization.

We have seen the success of utilization incentives with the recent Medicare CMS program for electronic prescribing. In fact, in our electronic prescribing unit, we are seeing increases in subscribers on the order of 30% a month, so it’s a dramatic pickup. But what the survey really said is that smaller physician groups are more in favor of an up-front stimulus and larger groups are more in favor of the longer term incentives for utilization. So, small groups want help getting over the hurdle to buy an electronic health record, and larger groups, who have in many cases already bought it, are looking forward to the incentives for utilization.

Why should the government pay for specific tools rather than results, like they pay road companies to improve highways rather than just buying them bulldozers?

Well Inga, I think you’ve captured what is the essential argument on Capitol Hill, where I was yesterday. That is, there is a lot of push-back on whether or not physician groups should be given direct incentives versus incentives on utilization.

The government and most people consider the e-Rx program — the 2% credit for utilization of electronic prescribing and then a 2% penalty, in other words, a carrot and a stick — as being very successful. That is what the bill that is currently sitting on the floor looks a lot like. That said, the current bill does give the Secretary about $5 billion to provide direct stimulus and potentially direct incentive to physicians.

So, there are two different versions: a $20 billion House bill and a $23 billion Senate bill. We’re not sure which bill will be pushed forward, but it looks like in either case, the Secretary will have immediate discretionary funds in the order of $5 billion to award to existing channels or in new programs. Those can be used for loans, for some of the existing grant programs underway in states, and lastly, direct incentives to physicians.

However, our view is that the direct physician incentives will be targeted most likely towards primary care, toward rural physicians, and toward physicians in under-served areas, as opposed to the general physician population for the reason you just suggested — that is, some people are asking why physicians need the government to buy them tools.

Allscripts offers a free e-prescribing tool, yet your own survey indicates that the majority of physicians don’t e-prescribe. What’s the guarantee they’ll use a taxpayer-subsidized EMR in ways that will benefit patients or reduce costs?

Again, what we have seen is that if you reduce the hurdle for adoption and then provide incentives for utilization, we do see an impact that’s coming. That is what we have seen with the successful CMS e-prescribing program.

I think the idea — and again, that is what gets to the debate — to the extent you can provide incentives for utilization, we believe that’s a very compelling reason why a physician would want to use an electronic health record. 

Our view is that a blended model of some incentives for adoption, especially for those groups that might otherwise have trouble paying for an electronic health record — that includes smaller groups, that may include primary care physicians or rural physicians — incentives will help that group of physicians, which comprises a very large number of physicians in this country, get on the electronic health highway. And ultimately that is a benefit to all of us in terms of quality and also in terms of cost reduction.

A recent Harvard survey showed that only 17% of Americans think more government money should be spent to increase the use of healthcare IT, ranking it last of all the spending options. With all of healthcare’s problems, why is IT the one to address first?

Our view is that you can’t address many of the problems in healthcare without information. So for example, you will hear people talk about comparative effectiveness — which treatments are more effective than others. The only way you can get to that decision is to have vibrant information that comes from electronic health records.

Similarly, we all know and we have all seen the statistics from the Institute of Medicine and other studies that there are billions of dollars wasted. Those dollars are wasted in terms of tests that shouldn’t be done, those dollars are wasted in terms of the 7,000 Americans who die each year from preventable medication errors, and the million and half Americans who are injured from medication errors. All those are enormous costs and those could be prevented by electronic health records and electronic prescribing.

I think it would be as if you were to say you want to improve the banking system and you want to reduce the lines at the old tellers windows we used to wait in, but you don’t want to use computers to do it. It’s inconceivable that you could improve the banking system without using computers that allow you to pull out money from your account when you are in a foreign country using an ATM. We have to get healthcare to the same standard that every other industry is up to in terms of information technology.

I think the public looks at the more immediate problem. It doesn’t look at the infrastructure problem. It says, “We have people without healthcare, how do we help them?” and they haven’t always made the connection between how technology can help.

How important is a national connectivity infrastructure for creating EMR demand by patients and doctors?

I think connectivity goes hand-in-hand with electronic health records. In fact, that is really why we call them electronic health records rather than electronic medical records. What we want to be careful of is replacing today’s paper silos in healthcare with electronic silos. What we need and what the current legislation requires is interoperable healthcare records. Allscripts has always been a leader in that area. That’s what we need. It’s very important.

You might recall that when computers first came out, people said that we would reduce the amount of paper that we used, and yet the amount of paper that we used actually grew. But once computers were connected through the Internet, all of a sudden we saw everything, from the number of letters sent by the US mail, to all kinds of transactions, even holiday cards and holiday gifts, starting to be sent electronically. Why? Because of that connectivity. A computer is a tool, just like an electronic health record is a tool.

The ultimate goal is getting our physicians in the US — who are the best physicians in the world — getting them the best information at the right time so they can make better decisions. EMR is simply a tool to make that happen. You got to get that tool connected to other tools to make it effective.

Stark provisions encouraged some hospitals to align with their physicians through technology purchases. How would the hospital-physician dynamic change if HITECH passes?

Well, you are still going to see the passage of HITECH will frankly give hospitals more money to support programs like the Stark relaxation. Today our surveys tell us that somewhere between 10 and 15 percent of docs are getting Stark-funded electronic health records and similarly, 10-15 percent of hospitals are participating in Stark.

We think that number is going to continue to grow. Hospitals understand that they need to be connected to the physicians who in many cases give them the referrals that are its lifeblood; that is their business. So they want to be connected. We think relaxing the Stark regulations was a positive move by the government, and we think that is going to continue to grow, and it’s likely actually going to accelerate based on the funding that comes from HITECH.

We should all understand that a year ago, we had an industry that was nicely growing. It has a number of very solid companies that are growing and that are competing. The level of competition is increasing. That is good for healthcare, that’s good for physician buyers, and even good for each of us like Allscripts and its competitors. That was a year ago. Today we have exactly the same dynamic, with the addition of anywhere from $5 to $23 billion. So almost wherever you put that, wherever that goes into the healthcare IT arena , it going to be very helpful to all the companies in healthcare.

People always try to make a comparison. Will this help you more than another company? We are talking about an immediate $5 billion injection. Five billion dollars is more than the entire size of the ambulatory healthcare industry, so you are saying we are not just going to get the industry grow, we are going to give it a stimulus of $5 billion, almost 2-1-/2 times the size of this industry. So it almost doesn’t really matter. Everyone in the industry is going to benefit from the HITECH bill, and the fact that the initial Secretary will have $5 billion to spend almost immediately is going to be very helpful to existing EHR users and to new adopters as well.

How do you anticipate it will help existing EHR users?

Well, first of all, the provisions as they currently stand, and having been on the Hill yesterday, I can tell you literally hour by hour some of these are changing, and being debated, and being marked-up. But the existing provisions would allow existing users of an electronic health record to upgrade that health record as part of their investment and get credits for it. And depending on which version you’re looking at, some of the versions actually give preferential treatment to organizations that have already adopted an electronic health record.

Are CCHIT-certified products a requirement to get funds?

What the current legislation says — and first of all, CCHIT requirement and having a certified system is absolutely critical, absolutely key in funding that will come through this bill. What the government has said is they are not certain that CCHIT is comprehensive enough or covers everything the government wants. So the current bill recommends that over the next 12 months that the government build upon the good work that CCHIT is doing, but continue to study and come back with guidelines that can be government recommended guidelines on what should be included in electronic health records covered by this legislation.

That said, the government also said but that, in the interim, we don’t want things to stop, so we are going to give the Secretary discretion to spend additional dollars on CCHIT-certified systems. So CCHIT certification is critical.

Every physician who buys ought to be buying a CCHIT system. There are more than over 50 of them out there. That’s a minimum standard. I think the government is saying if we are going to spend taxpayer money, we want it to go further, especially in the area of interoperability. The government is worried that they might spend any money on systems that don’t connect. They want to make sure that if they are going to spend money that it’s smart use of the government’s money; that it is going to be on systems that will connect. That’s one of the places that, as you know, Allscripts excels.

Will there need to be a privacy compromise to get HITECH passed?

Right now there are some privacy provisions that are troubling to the industry in general. We are big supporters of the current HIPAA provisions and other provisions that protect patient privacy, because at the end of the day, we are all patients and that is important.

That said, the current bill extends those privacy provisions which would increase the costs, for example, for electronic health record vendors. At the same time, there are a few provisions in there that actually impose a stricter requirement on the user of an electronic health record in terms of verbal disclosures and the like, than people on paper. We are working with folks drafting the bill to say, “Privacy is important, the standards ought to be the same whether you’re using paper or electronics.” The net-net, once again, the overall benefit to the industry of the bill outweighs any of the potential downsides of this bill.

Assuming the government decides to subsidize EMRs and demand increases, where will vendors get the experienced staff needed to implement and support them?

I think it is incumbent on vendors to do two things. One, at Allscripts we are working very, very hard to make the implementation process, the conversion process, easier than it’s ever been before.

You mentioned our free electronic prescribing product, the National ePrescribing Patient Safety Initiative (NEPSI.) As you know, that requires no human intervention to implement, so if a physician goes onto our Web site, he or she authenticates, which is a very detailed process. Once they are authenticated and put in administrative information, within as little as 30 minutes they can be writing prescriptions. There is no separate training required. It’s completely intuitive; it’s just like Google. Everyone gets it. From that perspective you don’t need more staff.

Now electronic health records are not there yet. But we, along with some of our competitors, are working to make these more intuitive and require less training. However, as we talk about the electronic stimulus package, should this package go through and to the extent it accelerates electronic health records use, that will drive employment in the industry.

What impact will Tom Daschle’s withdrawal have on President Obama’s healthcare reform agenda?

I don’t think there is any question that Tom Daschle was respected on the Hill. With any government program, there are two things you need: you need a plan, and that plan can be well thought out or sometimes not. And then you need someone who knows how to get it done, get it passed, to get it accomplished and executed on Capitol Hill.

The Obama administration has been very clear on their plan, which makes substantial use of electronic health records. But, Daschle was seen as someone, given his experience, who could get it executed on the Hill. From that standpoint, I thought he was an experienced person; he was also a person that President Obama had a personal relationship with.

Replacing Tom Daschle is going to be a challenge, but they are there are qualified candidates and I am confident the Obama administration and the vetting team will find them. I also think President Obama has been very clear that he expects to sign this bill very quickly, based on the signing yesterday, for example. Some of these bills are getting signed in very short periods of time, with limited debates and limited amendment. I think we see the government working very quickly to execute on President Obama’s agenda and to demonstrate to the economy that things will get better.

Are you being vetted for the Secretary post and would you tell us if you were?

(Laughs.) I am not being vetted for the Secretary post. But if I was, I probably couldn’t tell you. But I am not. I am very focused on Allscripts and I think the best place I could spend my time is to help physicians in this country, the best physicians in the world, get the right tools to deliver high quality care and do that at an affordable cost.

What will the industry look like in five years if HITECH passes?

I think President Obama’s dream, his vision, and what would be best for all of us is to have physicians not just using electronic health records, but using electronic health records as part of an interconnected healthcare system that allowed them to get the right information at the right time for better care.

We talk at Allscripts not about healthcare, but about connecting to health. The real idea is to try to keep people healthy, to proactively treat them using these electronic tools, and to deliver better healthcare. In this country, we spend more than any other in the world, and yet today our healthcare isn’t number one. Almost without saying, if you assume that our physicians and nurses are the best in the world — and most people acknowledge that — then you have to start to look and ask why is we can’t deliver this. It is because of the inefficiencies in the system.

When we think about the next five years, we are excited about the prospect that physicians will be using tools that bring them into the current times. And we are excited to be a part of that.

The latest I heard is something will be signed in the next couple of weeks – is that your understanding?

Not only is that my understanding, having spent the day with staffers and the leadership of both the House and the Senate, President Obama has made it very clear that that is his expectation to sign by Presidents’ Day. Speaker Pelosi has said she would cancel that holiday if they needed the time to work on this bill. The expectation was very clear.

If you look at what happened with the bill passed yesterday, essentially there was some debate as there is now between the House and Senate version. The Senate said, “If you want this passed today, pass it with our version.” There was agreement and it was passed and signed. We expect that the healthcare bill, the HITECH bill, will go through with very little amendment and adjustment and that it will be signed very quickly.

Anything I left out that you want to share about the whole process?

I’d say two things. There is an almost surreal debate going on with some of the analysts in the industry who are saying will we get $23 billion or we might only get $20 billion. Other people are saying this may not help because you may only get $5 billion. I must remind people that 12 months ago, we weren’t getting any billions. A billion is still a lot of money in our book. This is going to be a very, very strong stimulus to this industry and that is number one. The clear message is that this is a strong stimulus to the industry.

The second message is to physicians is that being on one of these systems sooner is going to help you participate in this whole stimulus game.

And the last piece of that is that this is a very, very unique opportunity for us collectively to fix healthcare. We at Allscripts hope that the industry does take advantage of this opportunity to do just that, because we know the power of information technology. We’ve seen it in every other industry in terms of improving quality and reducing cost. Now it’s time to bring power and promise to healthcare.

The most important question here: favorite interviewer: Jim Cramer or Inga?

Actually, I think both of you are wonderful.

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Currently there are "25 comments" on this Article:

  1. Is anyone stopping to ask how the PATIENT feels about having their private health information stored electronically? As someone who has had to deal with the (luckily minor, but could have been worse) headache of having their identity stolen from a major bank, I am even less comfortable with the thought of how much access my medical information would be subject to. I’m not saying it’s a bad thing – I just haven’t heard anyone address the Electronic Health Record from a security perspective.

    And, if I refuse to allow my information to be stored electronically, does that mean I will have to give up receiving care as well?

    Just wondering out loud…

  2. This article was interesting.

    Free EHR money? Like anything is free?

    Here again, we have this dichotomy between ambulatory and IP environments. And no interoperability between the two. Frankly, problem lists are probably easy enough. Having a lexicon by which we communicate interventions is a bit more difficult. Outcomes? Tantamount to impossible.

    Mapping of laboratory results? Extraordinarily difficult. LOINC – great concept – but difficult and fraught with barriers.

    Radiology? God forbid that anyone thinks beyond a textual result. And to apply LOINC standards? WHAT? LOINC? Parsing? Standards?

    Do we really need EHR’s? Should we simply be analyzing more the data that we have? Maybe we should focus on ICD-10-CM, data analysis, laboratory data interchange, Rx interchange – and electronic Rx prescriptions… ……..to quote the King of Siam, et cetera, et cetera, et cetera.

    Regardless, I do not forward to the HIMSS Bistro.

    If you have time to join a glutton in his repast, please join me.

    Arlen

  3. Excellent interview. One aspect of the interoperability I haven’t heard much about yet – the difficulty admitting physicians and other providers are having moving across systems. Pen and chart – though a lousy information management system, is highly interoperable from a user interface perspective. Talking last night with an oncologist colleague, he has abandoned admitting to another area hospital (using Epic) because he doesn’t use it frequently enough to really learn the system and it is significantly different from systems at other hospitals. I’m hearing anecdotes of disruption in care continuity because of these barriers – information can move more freely, but practitioners cannot. What are reader’s thoughts about the implications of this? Will we be hearing more about patients having to change long-time physician relationships – now not because of insurance chages, but because of EHR incompatibility? Is this just a transient issue?

  4. Care continuity in the electronic environment only makes sense if it is constructed as a virtual care plan. A virtual care plan would be structured with standards that all EMR systems would connect with. An authorized provider could contribute to the virtual care plan as well as understand the health information contained therein, because all information would relate to the patient’s care plan. Anything less than this permits the continuation of silos.

  5. Doesn’t anyone else have a problem with a company that has so much to gain from this bill, lobbying for it. In the end, we the taxpayers will be paying for the doctors to purchase a EHR system that they may or may not use. Either way they will get the money.

  6. Can anyone tell me if there are any definitive, 3rd party studies that document EXACTLY what benefits, improvements to care or productivity increases can be attributed to adoption of traditional EMR, such as Mr. Tullman’s product?

    There are several studies that document that traditional EMR deployment has shown NO positive ROI, no better standards of care or outcomes…and actually decreases the number of patients a physician sees in a day, with attendant loss in Revenues. Not to mention the cost of implementing EMR itself

    Every vendor has a few references they can tout, but STILL, multiple sources quote failure and de-install rates of greater than 50%, an adoption rate of 17% or so and costs that DWARF the $41,000 per provider (and the costs are NOT spread over 5 years).

    Throwing $5 Billion….or $20 Billion at those numbers seems to suggest we’ll have an avalanche of failed installs or de-installs…and a lot of practices who will invest all the money…and not be reimbursed for it because they won’t be using it….let alone “meaningfully”.

    This disappointing situation has NOT been improved with the onset of CCHIT standards over the past three years. The major reason for this is because the physicians themselves have not contributed to standards…otherwise the qualifying products would be much easier to learn, faster to implement and NOT slow physicians down and cost them revenues.

    Is there something out there use something that they were enthusiastic about right from the start… and still are? Is hybrid EMR an option?

  7. Counterpoint to some misconceptions Mr. Tullman’s comments might cause both in Washington and with physicians around the country:

    The stimulus plan calls for $20 billion in HIT incentives. Before spending this exorbitant amount of money, a little reality check is in order to see if this money is a wise investment.

    EMR systems have been the topic of many studies with conflicting conclusions regarding savings to the healthcare system, quality of patient care and the efficacy of computer-generated documentation. But when landmark studies examine the impact of traditional EMR on physician practices, the clear, consistent conclusion is that traditional EMRs negatively impact physicians and their practices which inhibits meaningful adoption. There are four such landmark studies ­performed by respected, venerable institutions:

    * A recent National Research Council report states that: (i) EMRs cause inefficient workflows; (ii) clinicians spend more time entering data than using it; (iii) meaningful interoperability is almost non-existent; and (iv) benefits are significantly less than anticipated. This landmark study was produced by a committee of industry thought leaders from many of the most respected organizations in the world, including Harvard, MIT, Stanford, University of Pennsylvania , Brown, Google, and Intel. Committee members shadowed clinicians using traditional electronic medical records software at nationally recognized centers of medical care.
    * In an enlightening New England Journal of Medicine article, renowned physicians and Harvard professors maintain that EMR technology diverts the physician’s attention from the patient and creates chart notes in a way that is seriously flawed.
    * In 2008, the Congressional Budget Office released a study that was submitted as testimony before the House Ways and Means Committee. The study claims that “office-based physicians may see no benefits [from traditional EMRs] and may even suffer financial harm.”
    * A U.S. government-funded study by the MGMA reported a decrease in physician productivity of up to 15% usually lasting a year or more. The study concluded that it is “difficult to establish a business case for EHR adoption.”

    For more information on the studies cited, please see the links at the bottom of this posting.

    Where are the comparable, unbiased, physician-focused studies that validate the successes of traditional, EHR technology?

    Why is the voice of the physicians not more prominent in this debate? It is the physicians­ who must take all the risk, shut down their practices, sometimes for days, to learn to use traditional EMRs, and suffer drops in patient volumes and revenues over a protracted period of time.

    Additionally, with reduced productivity resulting from traditional EMR adoption, how will physicians meet the huge increase in demand for their services stemming from the aging baby boomer population and the anticipated addition of millions of newly insured patients under the new Administration’s long-term healthcare reform plan? Compounding this pending spike in demand for physician services is the ongoing shortage in the supply of doctors graduating from medical school, particularly primary care physicians interested in practicing in underserved areas. A “Perfect Storm” is brewing.

    If the government wants a massive uptake of electronic medical records, they should promote alternative systems such as hybrid EMRs that have been gaining so much traction with ambulatory medical practices. Hybrid EMRs bring about the benefits of traditional EMRs without the doctor having to use rigid, click-intensive, cumbersome and time consuming systems that, studies have shown, negatively impact physicians and their practices. Hybrid EMR creates a digital office where critical patient information can be accessed, searched and shared at Internet speed.

    Only when it is EASY for physicians to digitize their practices can there be a critical mass of portable data that will truly result in the quality of care, efficiencies and cost savings that the payers so desperately want.

    ———

    For more information on the studies cited, please use the following links:

    National Research Council report: http://books.nap.edu/openbook.php?record_id=12572&page=R1 and click the “Sign in to download PDF book and chapters” link.

    New England Journal of Medicine article: (https://articleworks.cadmus.com/doc/dSoftcopy?o=708456&i=874832&c=1760334&atDownload=true) Caution: The New England Journal of Medicine is highly sensitive to the use and reproduction of their content. The link above brings you to a site where you have to download and install a small application on your computer to view a pre-paid copy of the article.

    Congressional Budget Office Report: (http://www.cbo.gov/ftpdocs/95xx/doc9572/07-24-HealthIT.pdf, see page 5).

    MGMA Report: Gans, David N. “Off to a slow start.” MGMA Connexion, 42. Oct. 2005. Available for MGMA members at http://www.srssoft.com/pdf/MGMA_Landmark_Study.pdf).

  8. What’s truly scary is that the Hill is now swept up in subsidizing CCHIT & e-RX rather than evaluating which HIT solutions can actually save CMS money. We all know HIT doesn’t guarantee savings, but our Medicare population will balloon to 75+ million in a few years and no HIT stimulus will solve that problem. Show me a CCHIT-certified EMR that functions efficiently in the mobile homecare environment in rural America (e.g. slooooow internet or no connectivity at all). We cannot exclude HIT solutions that keep our mothers & grandmothers out of the ER simply because they don’t comply with the CCHIT cartel’s requirements.

  9. The National Research Council report which definitely says EMRs don’t cut it just so happens to Google and Intel on the committee which both have massive interests in physicians not using integrated systems what a shock. It is also fitting that this little commercial is from the CEO of the Hybrid EMR leader.

    The past was best-of-breed systems. Research on the improvements in patient health that EMRs can facilate are everywhere. ROI for organizations improving health and reducing is well documented. Is our goal more EMRs? more Money? No, it is improved patient outcomes.

  10. RealityCheck,

    Hybrid EMR focuses on physician productivity – period.

    More productive physicians are better suited to provide better and more efficient care for patients.

    The point of my posting was to highlight the fact that there are no landmark studies that show significant benefits for front-line physicians using traditional EMRs and that there is overwhelming evidence that traditional EMRs limit physician productivity!

    Why would a physician purchase a traditional, rigid, point-and-click EMR with evidence to the contrary? Along the same lines, would a physician prescribe an infected patient an antibiotic that has a high incidence of failure, when an alternative antibiotic can be prescribed with proven, consistent efficacy?

    As trained scientists, physicians practice evidence-based medicine which means that their clinical practice is based upon valid clinical research. They need to apply the same evidence-based approach to evaluate technology purchases. When they do their due diligence, informed physicians discover an abundance of data that refutes the lofty claims of the traditional EMR industry.

  11. I always chuckle when someone at Allscripts/Misys (like Mr. Tullman in this case) preaches about interoperability (under the umbrella of CCHIT) when they mightily struggle to make their own products interoperable with each other.

  12. Among others, I can think of an excellent reason for the medical community to “get with the program” and join the 21st century as regards technology. Natural disasters can render inaccessible, or destroy completely, paper chart patient records. This can prove to be very dangerous for patients being cared for by a provider who doesn’t have the whole picture of that patient’s current and historical medical information.

    One specific example of this involves a medical practice in the San Diego area that was impacted by the wildfires in the fall of 2007. Their use of EHR software, allowed them to provide uninterrupted care for their displaced patients even while the clinicians were, themselves, displaced from several of their offices. The accessibility of patient information allowed clinicians to respond to the many calls from patients in immediate need of medical attention, and do so with full chart information at hand. Read the whole story here.

    I wonder how many Katrina victims wish their provider hadn’t relied on paper records?

  13. EMRs, like all new technologies, are only as good as the user’s motivation to make a successful adaptation. That’s part of the reason there is no definitive study out there proving one over the other. Each hospital, doctor, nurse, etc. do things differently and, unfortunately, there is no one size fits all EMR. Some find the new EMR workflows congruent to their own and the EMR proves successful. Others find themselves at a crossroads between changing their own methodology and simply wiping their hands of the whole mess. The problem is, once they reach this crossroads there isn’t much of an incentive ($$) to choose option 1. This stimulus package does just that. It’s not giving doctors money to buy an EMR, it’s giving them a financial incentive to push through, adapt to how the EMR works, and force themselves to be successful.

    I love online banking; it’s proven to be a very time saving system for me. However, there are many people who refuse to do it and they all have their reasons. It’s not secure, my internet is slow, I can’t pay all of my bills online, I don’t trust it. These are all valid issues, but they are temporary and solvable issues. As technologies age, today’s problems are solved and they grow into more powerful systems where they find more obstacles. If at each obstacle we say stop, no progress is made.

    I’ve read all of these comments and understand the issues some of you have made, but I ask two questions of you:

    Which of these issues are permanent, unsolvable problems?

    If there was a magical solution to the issue you’ve expressed, would you change your opinion on EMRs?

  14. Inga- fascinating interview!

    Dear Mr. Tullman:

    Thank you for coming on Histalk for an interview. This site is read on a daily basis for those of us with an interest in HIT, and having you come to visit is wonderful.

    Didn’t President Obama pledge not to surround himself with lobbyists? Aren’t you, your company, and your coworkers the ultimate lobbyist group, showering Obama with donations for the past 2 years alone? From what little I could find on the Google, you personally gave President Obama at least $144300.00 in donations in the 2 years prior to his election.(1) Your employees gave $20662 during the same period.(2) Your company, Allscripts/Misys also gave the possible future HHS Secretary Daschle $12000 speaking fees on 8/2008 for a lecture.(3) Now this activity seems to have put you into the unusual position where you are the personal advisor of the President of the United States of America on how to channel money to your company, ultimately enriching yourself while the American taxpayer, and especially doctors have to foot the bill. President Obama has put the wolf to guard the hen house!

    You can’t believe how much I resent the fact that you, a vendor selling a product is now in a position of power where you can determine how Medicare pays me, a physician. I’m sure that I’m not the only doctor out there that feels this way. Unlike you, I don’t have the lobbying power to get Obama’s ear. You’ll be able to sign up in the short-term those who already have EMRs, but once you get close to 20% uptake of these incentives, you’ll begin to bump up against the less CCHIT-certified-EHR-hard-core, more knoledgable physicians like myself who don’t want to buy into a multi-thousand dollar EHR to please the likes of the Medicare pinheads in order to be able to get paid adequately for our work. What this bill will eventually do is to damage Medicare as physicians refuse to see new Medicare patients or disenroll altogether. It also will begin the process of destroying the small solo to group office over the next 10 years, offices where 75% of doctors work in currently. These offices won’t be able to survive under the burden of these unfunded, onerous, unneeded mandates that you are trying to promote to satisfy your agenda. Students will think twice before going into medicine if not only do they now have to pay off their loans but also pay for a $30000.00 CCHIT-certified EHR, and worse yet, use it.

    Lastly, you mention that “[CCHIT-certified EHRs are] a benefit to all of us in terms of quality and also in terms of cost reduction” without there being any real data showing such. In fact, there is data showing the opposite.(13) Recently we’ve had alerts about data input errors from both the JACHO and the US Pharmacopeia.(4,7-12) You have the National Research Council finding that HIT systems used by several major health providers has fallen short of achieving healthcare delivery goals envisioned by the Institute of Medicine.(5) Recently, two HIT experts have penned an open letter to President Obama, warning him against investing too many federal dollars in existing electronic health records systems.(6) David Kibbe, MD, a technology adviser to the AAFP, and Brian Klepper, PhD, founder of consulting firm Health 2.0 Advisors stated that existing EHR systems are:

    –too expensive,
    –difficult to implement,
    –disruptive to practice workflows,
    –not proven to improve patient care, and
    –don’t do a good job of sharing information with each other

    So Mr. Tullman, do the right thing and stop the insanity of using taxpayer money to bail out a portion of the economy that doesn’t need the economic help, at least not in this way. If you can do me a favor- show this letter to the honorable President Obama so that he can get an idea of how the other side feels.

    Sincerely,

    Dr. Borges

    Citations:
    1) http://www.campaignmoney.com/political/contributions/glen-tullman.asp?cycle=08
    2) http://fundrace.huffingtonpost.com/neighbors.php?type=emp&employer=ALLSCRIPTS
    3) http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=389×4968435
    4) http://www.jointcommission.org/NewsRoom/NewsReleases/nr_12_11_08.htm
    5) http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090109/REG/301099965/-1/TODAYSNEWS
    6) http://medicaleconomics.modernmedicine.com/memag/submitBlogEntry.do#blog_confirmation_anchor
    7) http://www.ama-assn.org/amednews/2005/01/24/prsa0124.htm
    8) http://www.jamia.org/cgi/reprint/14/3/387.pdf
    9) http://www.nytimes.com/2005/03/09/technology/09compute.html?ei=5089&en=402b792e748d99a2&ex=1268110800&adxnnl=1&partner=rssyahoo&adxnnlx=1150474153-xVix1BcYkvTKJpuLyHStrQ
    10) http://jama.ama-assn.org/cgi/content/abstract/293/10/1197
    11) http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_42.htm
    12) http://www.usp.org/products/medMarx/
    13) see my 2 slideshows located here (~130 slides full of data)- http://msofficeemrproject.com/Page3.htm

  15. Long Haul:

    You mention that the stimulus package money will give doctors enough of an incentive to force themselves to be successful with traditional EMR. Will the $41,000 over 5 years really make it worth the effort for doctors? For most specialists, this amount is less than 1% of their total revenues each year. For primary care doctors, the incentive is less than 2% of revenues.

    Are the tiny incentives (as measured by percent of revenue) enough to overcome the productivity loss stemming from traditional EMR use? Most EMR’s are just not “usable” by any reasonable physician-based standard. If a high volume specialist sees 1 patient every 8 minutes (about 500 seconds), then slowing him down by 10 seconds per exam (2% of the 500 seconds) creates a productivity loss completely wipes out the incentives and immediately puts the doctor in the red – and the doctor is still stuck with the costs of implementation, hardware, ongoing support and verbose, robotic exam notes lacking “heart.”

    Many will challenge my statement above that traditional EMR systems slow doctors down – after all, my company has the most to gain from physicians not purchasing traditional EMR. While the landmark studies uniformly point to traditional EMRs reducing physician productivity, doctors should perform their own due diligence. They should simply document a few of their exams the way in which they are accustomed (dictate or handwrite) and time it with a stopwatch. Then, they should have the EMR salesperson (ostensibly a super user of the product) do the same. Once this benchmarking is done, physicians will have an objective understanding of what “usability” is. Then the doctor will be well-equipped to decide if the $41,000 incentive makes financial sense. (Don’t forget to add in the time/cost that will be spent in trying to document and report on “meaningful use” each and every year to earn the funds…for which CMS has a poor track reputation already under PQRI).

    Traditional EMR is NOT the “magical solution” envisioned here; to achieve what is necessary, the EMR must also be “usable”….and that’s why there is hybrid EMR.

  16. Dear Mr. Tullman:

    From comparing the comments following this interview to those that followed previous soft, HIStalk interviews, it appears that you are squandering respect, and bringing damage to CCHIT every time you open your mouth. It looks to me like you tasted the sweetness of tyranny granted to the biggest campaign donors by politicians, and predictably abandoned the demands of your customers, and lost the feel for hard work in the marketplace – where one has to compete to survive.

    To the layperson who is paying attention to your scheme, it appears that you are more interested selling your goods to Wall Street rather than to the doctors who actually need EMRs.

    Now that you have had the opportunity to shamelessly and irresponsibly promote Allscripts using yet another safe, feel-good interview on HIStalk, why don’t you come out into the open and respond to the critical comments from Ross D. Martin MD, Evan Steele and Al Borges MD? It looks like there are real people outside your circle of buddies with real jobs who want to take a shot at your ideas. (They don’t seem to like you very much, either).

    So come on out and defend yourself in a real interview right here.

    Or are you chicken? D. Kellus Pruitt

  17. As the owner of AmazingCharts.com (an EHR company – and competitor of Allscripts), and a family physician, you would think I would be the first person pushing to get government money for this technology – well, I’m not.

    Don’t give us money for technology. Give us money to provide good evidenced-based care and compensate us for our time (e.g., phone calls, paperwork, etc). And when I say money – I’m not saying $10 here or $20 there after filling out paperwork to submit to insurers or the government.

    What is atrocious about this whole thing is how we are ready to throw all sorts of money to big-business EHR software companies who charge absolutely ludicrous amounts for software, because they can. WAKE UP! Why should an EHR cost so much? It is just software, and frankly not nearly as complex as software like Quickbooks or Microsoft Office – and those cost well under $1000 for a license. So what is wrong with this system?

    Well, it looks to me, that somehow the government has not done due diligence here, and has brought in business people to make these decisions. We have allowed insurers to tell us that they’ll compensate us a few dollars more if we use a CCHIT certified product – which really means nothing other than the vendor that is certified had to pay 40K to apply for certification and 6K a year from now on. And soon, CCHIT may become obsolete as the government institutes its own certification criteria (one can image the complexities and hoops that the overworked physician will need to jump through to use such a government-dictated product).

    Look at e-Prescribing. Here is, what seems to be a great idea, whose implementation has been a nightmare. Scripts sent to pharmacies who say they didn’t get them (they didn’t check the computer correctly), and now calling back the practice – increasing the workload. Docs turned off from e-Prescribing because they didn’t get to their refills in 48 hours. No ability to send narcotics through the system (requiring docs to use more than one approach to prescribe for the same patient). And the most egregious – charging docs to use e-Prescribing!

    Bottom line – slow down. Let’s figure out what – exactly – makes for better and more efficient care, and stop pushing docs to adopt overly complex and ludicrously priced software!

  18. Dr. Bertman,
    Physicians don’t have to pay for e-Prescribing. This is a free service available to any physician who signs up online, as outlined at the National E-Prescribing Safety Initiative (NEPSI) website:

    The National ePrescribing Patient Safety Initiative (NEPSI) is a joint project of dedicated organizations that each play a unique role in resolving the current crisis in preventable medication errors.

    Electronic prescribing (ePrescribing) is a viable solution to counter shortcomings of the current paper-based prescribing processes that are in large part responsible for these errors. However, accessibility and cost barriers have slowed adoption of ePrescribing by providers.

    Until now.

    The goal of NEPSI is to increase patient safety by making ePrescribing accessible—and desirable—to all physicians and medication prescribers by providing it free of charge.

    The ePrescribing software provided by NEPSI is

    Simple – Online prescribing is easier than a script pad

    Safe – Instant checks on drug interactions, dosage levels and patient-specific factors including prior adverse reactions

    Secure – Patient information protected by privacy and security measures including prescriber authentication

    Free – Provided without cost by Allscripts and the members of NEPSI

    There are 1.5 million adverse patient incidents each year due to handwritten prescriptions that can be avoided with the use of electronic prescribing, and I suspect it won’t be long before the limitations applied to narcotic medication will be lifted so two prescribing methods will no longer be necessary. It’s about time the medical community joined the rest of us in the 21st century, and dump archaic, and unsafe, paper methods.

  19. For the record, while NEPSI is a joint project that includes Microsoft, Google, Dell, Cisco, Fujitsu, etc., the ePrescribing software is provided by solely Allscripts.

  20. I agree wholeheartedly with Dr. Bertman’s well thought out letter-to-the-editor! I just recently wrote an article in my monthly column on MDNG magazine on this very topic called “We Should Not Be So Quick to Rush into E-prescribing”, URL- http://www.hcplive.com/mdnglive/articles/PC_rush_into_e-prescribing.

    >>> Physicians don’t have to pay for e-Prescribing. This is a free service available to any physician who signs up online, as outlined at the National E-Prescribing Safety Initiative (NEPSI) website

    As long as Allscripts does not integrate with the vast majority of EHR systems, it is not really free. The way it is being promoted, it is more of a demo of Allscripts than a real workable solution. It’s a marketing ploy to get physicians accustomed to using the full, expensive, “enterprise” level Allscripts software which most docs in small offices would find to be overkill.

    If a physician does not buy the Allscripts EHR, then he or she will have to pay to get software to integrate e-prescribing with his current EMR or be forced into an unworkable double-entry situation, which will intrinsically increase the chances of making a prescription error.

    >>> Electronic prescribing (ePrescribing) is a viable solution to counter shortcomings of the current paper-based prescribing processes that are in large part responsible for these errors.

    First of all, there are many like myself that have an EMR that sends prescriptions either to the printer or to a fax machine, so I don’t turn in hard to read handwritten prescriptions.

    For drug interactions I use a truly free software- the Palm-based ePocrates. It even gives me price comparisons, formularies, adverse effects, etc. I don’t need an EMR to immerse my Win XP screen with pop-ups that are annoying and which may slow me down.

    Privacy is ensured as the patient takes the prescription to the drugstore of his/her choice. There are no intermediaries to deal with. Narcotics? No problems.

    >>> There are 1.5 million adverse patient incidents each year due to handwritten prescriptions that can be avoided with the use of electronic prescribing

    Again, my prescriptions are NOT “handwritten”, but Mr. Tullman’s advice to President Obama is to simply send everything through Allscripts, I guess to maximize his profit.

    That aside, if you look at the US Pharmacopedia’s 5th annual study of medication errors, it’s true that there are a lot of medication errors with handwritten prescriptions, and in fact they found that illegible or unclear handwriting accounted for 2.9% (6,134) of reported mediation errors, and it ranked as the 15th leading cause of these errors. That’s high, but pales to computer entry errors, which accounted for 13% (27,711) of the medication errors reported in 2003, which ranked as the 4th leading cause of errors.

    So that translates to a 4.5 fold increase in errors if one chooses to use e-prescribing as per the results of that study. I have yet to see a sound, scientific study that actually demonstrates an increase in quality, a decrease in errors, and/or decrease in costs associated with e-prescribing OR with the use of a certified electronic health record (c-EHR), yet President Obama and Mr. Tullman want to ram these initiatives down the throats of hard working people- this nation’s physicians.

    On 12/8/2008 the Joint Commission (JACHO) that certifies hospitals issued an alert and warned that “implementation of technology and related devices is not a guarantee for success, and may actually jeopardize the quality and safety of patient care.” They also stated that “…any form of HIT can have a negative impact on the quality and safety of care if it is designed or implemented improperly or is misinterpreted.”

    These HIT initiatives send a chilling message that Mr. Obama really doesn’t care about the “working class”. The abusive issue of forced unproven costly mandates, of penalties and of other cutbacks in reimbursement will only work to make certain vendors that have donated to his cause richer and will eventually destroy the busy small businesses that make up 75% of the clinical system in the USA. President Obama and his HIT adviser Mr. Tullman are jeopardizing the very existence of Medicare.

    All of the URLs can be found in my (REALLY FREE) downloadable PPT presentation, “HIT in the USA Under President Obama” located here: http://msofficeemrproject.com/Page3.htm

    Al

  21. LadyGreen states “The goal of NEPSI is to increase patient safety by making ePrescribing accessible—and desirable—to all physicians and medication prescribers by providing it free of charge.”

    What she did not mention is that if you use and EMR and NEPSI, then you’re relegated to double entry- writing the script once in NEPSI and then again, recording it in your EMR. You see, Allscripts purposefully did not provide a bidirectional EMR interface with the software. Does Allscripts have the expertise to do that? You would certainly hope so. So while the tone of her note depicts Allscripts as altruistic, there is no altruism in their corporate offices.

  22. Most decent EMRs should have an integrated e-prescribing tool If your EMR doesn’t have free e-prescribing or an integrated e-prescribing tool, then why is that Allscripts fault?

  23. My EMR has an “e-prescribing” tool that I’ve been using for the past 19 years- it sends all prescriptions to the printer. It does not comply with buy-my-way-to-power-via-Obama Glen Tullman’s fabricated e-prescribing rules. Because of this, as a physician I’ll lose up to 5% of my income eventually. One poster called Tullman’s ability to set physician’s fees through Medicare a “cross occupational piracy”.

    I think that the one that has to comply is Obama with a federal law called the Hobbs Act (18 U.S.C.A. § 1951 [1994]) which makes it a felony for a public official to extort property under color of office. Trading campaign contributions for promises of official actions or inactions are prohibited under this act.

    There are a lot of angry folks out there: “Obama, Tullman- are you listening?” If President Obama is going to take on lobbyists, then he should start in his own back yard.

    Al







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