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June 14, 2010 Readers Write 20 Comments

Submit your article of up to 500 words in length, subject to editing for clarity and brevity (please note: I run only original articles that have not appeared on any Web site or in any publication and I can’t use anything that looks like a commercial pitch). I’ll use a phony name for you unless you tell me otherwise. Thanks for sharing!

The EHR Manifesto
By Recently RIFed

A spectre is haunting America — the spectre of Meaningful Use. All the powers of traditional vendors have entered into a holy alliance to exorcise this spectre: Executive Office and ONC, Allscripts and Eclipsys, Epic, Cerner, McKesson, and Meditech.

Where is the software vendor that has not been decried as unusable by its opponents in power? Where is the software vendor that has not hurled back the branding reproach of unusable software, against the more integrated vendors, as well as against its reactionary adversaries? (My apologies to Karl and Friedrich).

10 Point Program to Improve EHR software

  1. Less configurable. The Demotivators® said it best “When people are free to do as they please, they usually imitate each other”. Every hospital or physician practice is unique — they uniquely solve the exact same problems everyone else is facing.
  2. Better designed. End-user input and UI design should be part of the specs, not the pilot.
  3. Customer-prioritized enhancements. Fifty percent vendor-driven (sales and demo feedback, regulatory requirements, infrastructure, etc.), 50% prioritized by customers. Yearly process, projects grouped to be equal number of hours, one vote per licensed bed, top x projects will be roadmapped to fill 50% time.
  4. Consensus-driven standard content and configuration. Vendor designed, large group customer editing — majority rules, everyone uses.
  5. Remote hosted. 99.999% uptime, capacity and response time are key requirements.
  6. Rapid install. If you’ve followed 1-5, training the end-users should be the most time-intensive phase of the implementation.
  7. Qualified buyers. We’ll sell to you if you agree to: follow our standard workflows, use our standard build and participate (end-user input, content design, and prioritization). Must agree to mandate adoption! Better to support 50 involved, committed customers than 100 unhappy, non-standard, partially-implemented, low-adoption targets.
  8. Equitable pricing. Low upfront, subscription-based. Every customer pays the same, scaled by size or volume.
  9. Play nice with other vendors. Integration > Interfacing > Interoperating.
  10. Record portability. Remove vendor lock-in. The intersection of the NHIN and CCDs with the market transitioning to replacement will make this a necessity. You know it will be mandated eventually.

I can’t think of a single vendor that would get a passing grade on my 10-point scale (even the industry darling would only receive a 40%). But please, prove me wrong and post comments. As I review my RIF package and dust off my resume, I’d love to be proven wrong (and find out they’re hiring) …

Personally, I’d love to see a new breed of vendors emerge. Maybe someone will submit a FOIA request and hire a team of developers and clinicians to polish and fill in missing functionality. Maybe even someone willing to follow my manifesto and explore a co-op or non-profit corporate structure. Forget the socialization of medicine, let’s socialize the vendors. Until that happens, I’ll continue to remain anonymous and try to work from within.

Jump-Start HIEs with Integrated Health Records
By Ravi Sharma

 ravisharma

One of the challenges that most EHR systems will have in satisfying the government’s Meaningful Use requirements will be to establish connectivity and interoperability with other providers’ systems and ancillary services. Disparate data from multiple providers must come together as a more complete patient-centric record to achieve this goal, and not all providers are ready for it. These and other business and logistical issues are some of the challenges that health information exchanges (HIEs) have encountered.

One solution is to use technology to leverage data generated through existing business relationships. This can be done through a Web-based, patient-centric “Integrated Health Record” (IHR) that integrates data from multiple sources and institutions. An IHR provides up-to-date, community-wide, patient-centric data such as lab and imaging orders and results, incorporating both hospital and reference labs.

It also can be used for ordering prescription drugs and leverage the patient’s allergies, drug history, and even lab data to prevent adverse events. Physicians can even follow the inpatient encounters for patients admitted in connected hospitals, along with outpatient data, from anywhere over the Web.

IHRs also improve the ability for patient care teams — physicians who must collaborate to provide comprehensive care — to coordinate care and share patient records. Today, such clinical information between referring physicians is shared via fax, mail, or phone. Even when practices have EHRs, they’re often unable to send key patient data electronically to other physicians who may be using different EHR systems.

The Meaningful Use criteria require such exchanges to occur using standards such as Continuity of Care Document (CCD) and the Continuity of Care Record (CCR), but few systems are capable of using such standards. That’s partly because EHRs aren’t designed for information exchange and also because, in the absence of HIEs, the transmittal of CCDs requires point-to-point interfaces. An IHR that already can create connections to multiple EHRs can act as a link to exchange CCDs or CCRs.

The IHR is not designed to replace EHRs or CPOE systems, but rather to collaborate with them to connect them with other information sources. In that sense, the IHR unifies and facilitates the patient-centric data exchange between various entities to realize the formation of HIEs. The IHR further facilitates the integration of data from multiple sources by normalizing data from disparate sources using standards specified in Meaningful Use, criteria such as LOINC for discrete lab data.

Rather than upfront investments in MPI and other expensive technologies, HIE pilots can greatly benefit from the use of technologies like the IHR. The IHR can not only serve as basic HIE, but facilitate HIE participation by providing key information where and when it’s needed on the front lines of patient care.

Ravi Sharma is president and CEO of 4medica.

Thoughts on Eclipsys-Allscripts
By Tim Elliott

The coming together of two heavyweights in the healthcare IT industry, Allscripts and Eclipsys, has the potential to open doors for their existing and future customers, third-party developers, and patients. There will be some challenges, too — including helping current customers integrate legacy Allscripts and Eclipsys systems alongside new modules — but this can be considered another opportunity for outside vendors whose technologies bridge the gaps between Eclipsys and Allscripts applications.

Detractors may be lampooning the Allscripts / Eclipsys “One network, one platform, one patient” slogan, but in truth, the merger does create a cohesive, cradle-to-grave care solution by uniting pre-acute, acute, and post-acute care information, as well as simplifying financial and performance management with non-clinical data.

The use of a common .NET technology stack offers the possibility of seamless integration and increased usability for clinicians and administrative staff. It also makes it easier for third-party software providers to deliver bolt-on solutions that further enhance Allscripts / Eclipsys offerings in physician practices, hospitals, home health, and other care environments. These external vendors will be crucial if Allscripts / Eclipsys is to succeed in bringing together previously disparate patient populations, which will require capturing and managing data from multiple sources in a centralized manner.

Tim Elliott is CEO of Access.

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Currently there are "20 comments" on this Article:

  1. This cast has much to say. Rifed is correct: “Personally, I’d love to see a new breed of vendors emerge.”

    Yes, they need to get rid of the ancient platforms, get rid the rigidity from enforced workflows, get rid the meaningful unusability inherent in the devices, and, last but not least, get them vetted by the FDA to assure a modicum of safety and efficacy.

    Thank you RIFED>

  2. Recently RIF’d is dead on! Having worked for a vendor, the notion of having a truly integrated UI, customer driven improvements and a reasonably short install tied to a set of standard workflows was a complete afterthought. In fact, the vendor types simply didn’t understand healthcare. At all. Why do we keep thinking that a technical industry like software houses understands a technical industry sector like healthcare – their business models couldn’t be more different nor could their skill sets. Sigh, there I feel better – wish it wasn’t so but it is.

  3. Recently RIFed 10-Point Program is brilliant if somewhat unreasonable. I’m that way too though and have always thought that all of Eclipsys’ customers striving to achieve the same results in their own similar ways was highly inefficient. In their defense, ECLP has been delivering some CDS templates that make doing the same things over and over again for different customers a heck of a lot easier (I feel that they’re making a very creditable effort in that regard.) Anyhow, great plan, RR!

    Detractors may be lampooning the Allscripts/Eclipsys merger but the efficiencies of the open platform might well prove them all wrong. As a developer, coding multiple apps to consistent context-aware objects makes integration both work easier and better (and look a lot better as well.) I wouldn’t bet against this deal (not that I’m betting and I’m not suggesting that you do either, either way (standard disclaimer.)

    I’m looking for a quantum leap and I’m thinking that they are as well.

  4. I feel that Recently RIFed is 100% dead on.

    It seems that reinventing the wheel is required when any vendor walks in the customer’s door with a signed contract. Learn from others mistakes? Share other hospital successes? That seems to only be a topic during the sales cycle.

    Comply with federally mandated criteria without customer pain and suffering and positive fiscal impact to the vendor bottom line? Not gonna’ happen!

    If Recently RIFed is successful in implementing the 10 Point Program to Improve EHR software I’ll drag out my pompoms and do a cartwheel! Good luck in your search RR!

  5. Worst Metaphor Possible: There may be many ways to describe the benefits of the Allscripts/Eclipsys merger/buyout/combo. But the worst metaphor for an EMR intended to help people stay healthy and alive has got to be calling it a “cradle-to-grave” product line. EMRs may be helpful in obstetrics, but its assistance in getting one to the grave may not be the best marketing approach.

  6. Re: Eclipsys-Allscripts
    Please expand on the .NET technology leading to seamless integration. Two .NET solutions might integrate well or not at all. What are the commonalities in how Eclipsys and Allscripts solutions use .NET?

  7. The EHR Manifesto makes for a good read, and seems to address most of the concerns I read about EHRs. As for the number one “Demotivator” advice: while I agree that most users don’t want to be confused by too many configurable options at all times, there are some users who will want to tweak things. My version of Word on my computer little resembles many, because I’ve gone into the advanced settings and modified things to suit my needs. I like doing that, but many are content with the default settings and don’t want to be confronted with too much decision making: they just want to type. I’d say there should be two levels of control: the standard for most people, and the more advanced functions that are further removed but still accessible to those who want to access them. That’d fit nicely with the #2 tip about usability.

  8. Re: The EHR Manifesto

    How’s this Manifesto, written by Octo Barnett?

    1. Thou shall know what you want to do
    2. Thou shall construct modular systems – given chaotic nature of hospitals
    3. Thou shall build a computer system that can evolve in a graceful fashion
    4. Thou shall build a system that allows easy and rapid programming development and modification
    5. Thou shall build a system that has consistently rapid response time and is easy for the non-computernik to use
    6. Thou shall have duplicate hardware systems
    7. Thou shall build and implement your system in a joint effort with real users in a real situation with real problems
    8. Thou shall be concerned with realities of the cost and projected benefit of the computer system
    9. Innovation in computer technology is not enough; there must be a commitment to the potentials of radical change in other aspects of healthcare delivery, particularly those having to do with organization and manpower utilization
    10. Be optimistic about the future, supportive of good work that is being done, passionate in your commitment, but always guided by a fundamental skepticism.

    Octo wrote them in 1970, and vendors still haven’t gotten religious…

  9. Agree w/ PeachEater. What ambulatory products at Allscripts are .NET and work? It’s not a trick question.

  10. As a grunt employee at one of the major vendors, I would like to provide an addendum to RR’s manifesto from an R&D point of view directed at senior management / VPs:

    1. If R&D is managed by Excel (that is, numbers of all flavors: sales, bonuses, headcount, project estimates, etc.), your staff will spend a majority of their time futzing with Excel and not developing a good product. This kills momentum and morale.

    2. If you focus more on your career path than on development, you will not get a good product. (Your true motivations are clear to those under you.)

    3. If you believe a catchy motivational slogan will inspire greatness from developers, you are completely without a clue.

    4. If you believe developers in India or South American understand healthcare as well as developers in the U.S., Excel is guiding your decisions, and the resulting product will reflect that.

    5. If the sales team is pressured into promising customers anything and everything to make a sale (customized code/features), they do so at the expense of your final product.

    6. If lower management is afraid to raise legitimate development process issues with upper / senior management decisions, your staff will work in chaotic conditions that keep compounding. (And kill morale.)

    7. Good developers do not necessarily make good managers. Recognize this and act accordingly. Good developers should probably remain good developers.

    8. Red tape — time tracking, project tracking, expense tracking, “quality” initiatives, performance tracking, etc. — might be important to someone managing by Excel, but it does little to get a good product out the door. Another way to say it, micromanaging sucks the life and creativity out of your employees.

    9. If you make mistakes (and you certainly do), admit them and move on. Your staff will respect your honesty. If you try to hide them or glaze over them, your staff will whisper about how obvious you are.

    10. If anything you do has been depicted in a Dilbert cartoon, you will get the final product that you deserve.

    All that being said, I’m sure there’s a top 10 manifesto from senior management to developers just waiting to be written!

  11. IHR is a good concept – it involves coordination, sharing, and exchange of patient health data. Mr Sharma, may I suggest that you advance the IHR concept one more click to “Virtual Care Plan” — a new paradigm that moves the notion of shared “records” forward to a patient care plan which exists virtually and provides a vehicle for every authorized view, edit, or addition of data. The difference between IHR and VCP is that VCP provides a rationale for arranging and managing data related to the individual patient’s health conditions. “Records” lose their boundaries and all data flows in and out of the VCP based upon its relevancy to the patient.

  12. AllScripts Eclipsys – The elephant graveyard of technology. Ambulatory clients across the country are struggling. Wasn’t Medical Manager a good enough example of what happens when?

    Good EHR Systems – not on platforms that pre-date the internet! Are we really serious about this or not?

  13. > not on platforms that pre-date the internet!
    SQL is fast and reliable. No point in criticizing it for being old. Better to evaluate on outcomes than age.

  14. Also a problem for Allscripsys integration is that Allscripts uses Medispan for its drug terminology/KB and Eclipsys uses Multum. No matter what they do: all Medispan, all Multum, or mediate between them with RxNorm, it is a TON of work just for that integration alone.

  15. Great post Recently RIFed. I couldn’t agree with you more.

    So, how could we organize a team of software developers and clinicians to collaborate and bring your manifesto to life?

    I’m serious!

  16. Great post Recently RIFed. I couldn’t agree with you more. So, how could we organize a team of software developers and clinicians to collaborate and bring your manifesto to life?

    Put someone who’s been trained in that type of intermediary role in the position. For example, see “The role of the information architect” by Sittig at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579195/

  17. re. Ross Koppel’s comment: “EMRs may be helpful in obstetrics, but its assistance in getting one to the grave may not be the best marketing approach” response

    ANSWER: While I agree that the word “grave” may not be the best marketing phrase for healthcare, the point was that the Allscripts / Eclipsys merged solution set would provide continuity from the physician’s office, through the referral process into the acute care setting and afterwards into the post-acute follow-up process back at the physician’s office. This complete solution set (if successful, which remains to be seen) can provide a competitive advantage to the Allscripts /Eclipsys organization.

    2) re.PeachEater’s comment: “Please expand on the .NET technology leading to seamless integration. Two .NET solutions might integrate well or not at all. What are the commonalities in how Eclipsys and Allscripts solutions use .NET?”

    ANSWER: You are absolutely correct, just because they are both .NET does not insure that integration will be smooth. However, having two system on a common platform overcomes many other obstacles. The development process when cobbling two different solutions together is ALWAYS easier on a common code base.

  18. Mr. Sharma has drunk the Kool-Aid and it is clear that he is so out of touch with the current market space.
    Interoperability isn’t a dream, it’s a reality for those vendors who haven choosen to invest in developing the technology that actually demonstrates interoperability.
    While Mr. Sharma can talk the talk about interoperability, he has yet to produce an interoperable system whereas other vendors have not only produced interoperability using IHE standards, they have tested and written the framework for doing so.
    Stop talking Mr Sharma until you have something to talk about.







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