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October 6, 2010 Readers Write 13 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!

EMR: One Size Does Not Fit All
By Evan Steele

10-6-2010 6-27-07 PM

A recent comment on HIStalk, by a hospital CIO about what he identified as the best EMRs for enterprise systems and their physicians, highlights a problematic and all-too-prevalent misconception. The fact is, it is impossible to satisfy both hospitals and community ambulatory physicians with the same EMR product.  Furthermore, even the ambulatory market cannot be looked at as a whole. EMRs designed for primary-care physicians respond to a set of needs that are very different from those of specialists.

Enterprise EMRs simply do not work in high-volume ambulatory practices. This is particularly true for specialists’ practices. Many hospitals have had some success with Epic and other hospital-focused EMRs, but success has been limited when these same hospitals ask physicians — again, particularly the specialists — to implement these systems in their practices. A monolithic enterprise product cannot possibly support equally well such different workflows, patient care scenarios, and providers’ needs.

Within the ambulatory market itself, it is time to bifurcate the EMR discussion into two groups: EMRs for primary care physicians and those for specialists.

Industry analysts typically lump all EMRs into one category, which does not adequately differentiate the market segments or their distinct needs. The major EMR vendors have massive footprints in the marketplace, yet a small company like SRSsoft has the lion’s share of referenceable high-volume, prominent specialty practices in areas like orthopaedics and ophthalmology. Why? Because one size does not fit all, and it is impossible to satisfy the needs of both groups without compromising the needs of one.

The American Academy of Orthopaedic Surgeons (AAOS) acknowledged this issue in its recently released EMR Position Statement, pointing out that “Many systems are geared toward primary care medical practice, which can limit the utility of EHRs for specialty surgical practice.” It correctly suggests that “the different needs and uses of EHR by disparate medical specialties should be recognized.”

Specialists represent approximately 50% of the physician market, a sizeable segment that is largely being ignored. How are specialists to determine which EMRs are designed for their needs?

KLAS, the closest our industry has to a JD Powers–type of rating source, does not break out its ratings by specialty. This means that if an EMR vendor does well in the ambulatory primary care market and has high KLAS ratings, an unsuspecting specialty practice might purchase their product based on those ratings, only to find out that the product does not fit their unique needs. 

Exacerbating the situation is the fact that KLAS only surveys practices that have actually installed the EMRs. It does not survey practices with failed implementations. Since specialists represent a disproportionate number of the failures, the information is even further biased.

The result is that there are thousands of specialists who purchase EMRs from highly rated and/or household name vendors, but who end up with failed implementations and significant financial loss.

One size does not fit all. There are good EMR solutions available for every type of physician. It is incumbent upon the individual physician to research and identify the product that best suits his/her practice’s needs.

Evan Steele is CEO of SRSsoft of Montvale, NJ.

ClickFreeMD Comment Response
By Bob Gordon

Note: Mr. H here. I’m breaking my “no commercial pitch” rule this one time because Inga had questioned the business model of ClickFreeMD, which offers practice systems including billing for a flat monthly fee rather than the traditional model of a percentage of collections. Inga’s point was that the percentage model encourages the billing company to collect. CEO Bob Gordon was nice enough to e-mail Inga an explanation and we thought his response might interest some readers even though it is hardly unbiased. I’m not endorsing their product and I have no connection to ClickFreeMD.

ClickFreeMD leapfrogs the percentage-based provider business model. Consider the following:

  • No start-up, implementation or training charges.
  • The flat fee is lower on an equivalent percentage basis than most practices would pay for outsource medical billing alone and far less than in-source options.
  • If the practice improves its revenue or we boost it (which we often can do), the equivalent percentage drops through the floor.
  • The breadth, quality, and integrated end-to-end nature of our software, services, and support are unrivaled. Physicians are paying twice as much elsewhere for much less elegant solutions today.
  • The flat fee sticks. If encounter or charge values increase, the flat fee stays the same and the practice captures cost free revenue. If it drops outside ordinary seasonality range, the rate is adjusted down pro-rata so our physicians’ earning power is fully protected.
  • Importantly, the flat fee is backed by a performance guarantee that makes sure we work every claim or we rebate half of the flat fee. There is no equivalent protection in a percentage-based model. In fact, any claim that takes more than 15 minutes to resolve in a percentage system is probably costing them more than they are making, and hence billing company profitability is at some point in the collection continuum inversely correlated to increasing practice collections.
  • Our contracts all have 90-day outs and low price match guarantees for comparable services.

You may ask how we do this. We have deep domain expertise from running billing companies, back offices, and technology companies for decades and have organized a Southwest Air-like discount fee, high-result business model that is very scalable. We expect that ongoing volume will feed a virtuous cycle for all, continuing to allow us to offer more for less while achieving top results.

One of the most striking things we are doing is the least recognized — giving the practice their flat-fee price, online and instantly, as well as their included services, without asking them to give us any information. Try this anywhere else like Athena and what we do in 30 seconds becomes a multi-day process that involves e-mail / telephone / online discussions and/or meetings and requires the practice undressing for the vendor. We are completely ONE-WAY transparent. That’s because we want the practice to decide if they want to contact us — after they are satisfied that this is a superior value for them and only then. We aren’t interested in lead nurturing them to death. 

This is about "more dollars for doctors" and great news in the group practice fight to sustain their independence. We are doing our part to create a reversal of fortune in the group practice community with a unique business model that raises revenues faster than costs, delivers immediate and ongoing savings, and provides the tools and support that allow them to be ready for tomorrow.  

Like the boiled frogs of lore, physicians have been nickel and dimed by payers, billing companies, and others, overpaying to under-produce for so long, they find themselves working much, much harder for less and less. We’re changing that and we’re passionate about it! Thank you for your consideration.

Bob Gordon is CEO of Click4Free of Chevy Chase, MD.

It’s Official: The Rush for Talent Has Begun
By Tiffany Crenshaw

10-6-2010 6-55-56 PM 

In recent weeks, a number of existing and prospective clients have called me for a pulse on the healthcare IT recruitment marketplace and thoughts on how to attract quality resources. After a number of such calls, I decided to put my thoughts in writing and share.

Let’s start with the good news. Industry hiring is definitely picking up and employed candidates are now less afraid to make a career change then they were three to six months ago.

As for hot products, it’s no secret that Epic is hot, hot, hot. Hospitals are purchasing Epic left and right. Honestly, there are simply not enough Epic resources, especially Epic-certified resources, to go around, so the talent war is raging. Cerner recruitment remains modest but steady, while McKesson needs are starting to rebound after quite a lull.

In the ambulatory market, we are seeing more and more requests for eClinicalWorks and Allscripts. New names like Sage and Greenway are coming to light. And occasional needs for Meditech, Siemens, IDX/GE and Eclipsys are surfacing.

On the integration side, Cloverleaf and e-Gate skills are still in demand, but we are seeing more requests for Web-based and lesser known products like Ensemble, Symphony, and Rhapsody.

The hiring demand is highest by far for hands-on resources to design, build, and install EMR applications. However, there is a fair amount of activity for sales, project management, and training professionals, including go-live support.

CPOE, clin doc, pharmacy, oncology, and HIM are generating the most recruitment activity within the applications. Based on new client requests, we foresee growing needs for business intelligence, security, and report-writing resources.

In addition to employers’ desire for one or more of the skill sets mentioned above, most are adding clinical designation to the requirements. Over 50% of our job requisitions right now require clinicians. Pharmacists, nurses, and physicians with healthcare IT experience are in great demand.

However, post-recession hiring is creating challenges previously unheard of in my 12-year history recruiting in this industry. The process is now wrought with excruciatingly slow interview scheduling, shrinking employee benefits packages, little to no relocation assistance, and financially conservative offers resulting in more and more frustrated candidates.

Things have changed drastically since the lowest points of the recession. After the release of Meaningful Use requirements, recruiting mania has taken off. Everyone seems to have hiring needs. Candidates are getting called left and right by internal and external recruiters. Just check out a few of the job boards if you don’t believe me — you’ll see countless job postings. Furthermore, check out all of the recruiting firms with no previous healthcare IT experience trying to break into this market as experts claim abundant need for resources.

If your organization is currently or will be in the market soon for these in-demand resources, you may want to evaluate your hiring process, recognize that your competition is fierce, and take note of a few trends our candidates and clients have shared with us quite candidly over recent months.

  • New car syndrome. Candidates are migrating to new implementations. Who can blame them? It’s more exciting to be on the ground level and see a project through from A to Z.
  • Red carpet treatment. Employers who roll out the red carpet win. When weighing decisions between job offers, candidates almost always choose the employer who provided quickest response time and showed sincere interest in them. (Both response time and sincerity are simple and no-cost ways to roll out that red carpet.)
  • Relocation blues. Relocation is a HUGE issue right now. Even if candidates want to move, they can’t do so because of the housing market. Kudos to all of the organizations willing to work around this by providing remote work, commuting, or coverage of interim living expenses.
  • Communicate. Many, many candidates are feeling jerked around by potential employers because of lack of communication in the interview process. Here’s what they are thinking: “If I don’t feel valued as a candidate, how are they going to treat me as an employee?” On the flip side, these candidates are communicating with plenty of their peers. Too many hospitals and consulting firms are getting bad reputations as being lousy places to interview and to work.
  • Too much is not always a good thing. In the quest for resources, too many organizations are panicking and calling in all of the troops — internal recruiters, employee recruiting bonuses, dozens of external recruiters and advertisements. Candidates get called multiple times by different sources all looking to fill the same positions. Not only do they end up confused, but all the activity makes candidates suspicious. They wonder what’s wrong with an organization that has such a hard time attracting and retaining talent?
  • Get on board. We are hearing more and more horror stories about candidates showing up on the first day only to find their new employer is not ready for them. This gets them off to a bad start from the get-go. Employees stay longer and perform better when they feel welcomed and the transition process is smooth. The period of time between offer acceptance and start date can also be a black hole, when candidates are most vulnerable. Employers are losing candidates this far into the game because they aren’t communicating with them. If you don’t have a formal on-boarding program, now is probably a good time to look into it.
  • Disconnect between human resources and hiring managers. As an outside firm, we work with both HR representatives and hiring managers. We hear complaints on both sides about the other on a regular basis — namely due to lack of response. The hiring managers want candidates fast. And HR wants answers fast. Throw candidates in the mix who get frustrated as well and it’s a nasty situation. However, we find that employers who really engage the final decision-maker in the process from beginning to end and set response expectations up front have the least amount of frustrations and the most successful outcomes.

In summary, you can safely say that the industry is quickly changing to a candidate-driven market and that the market is impacted heavily by post-recession recovery and Meaningful Use. It is official. The rush for talent really has begun.


Tiffany Crenshaw is president and CEO of Intellect Resources of Greensboro, NC.

The Coming Speed Bump in the EMR Market
By Jon Shoemaker

It’s no secret that there is currently a mad rush occurring, not unlike The Oklahoma Land Rush of the 1800s, where hundreds of companies both new and old are getting into the business of healthcare information technology. Some come with industry expertise. Others come to take advantage of the financial opportunity. Consider Best Buy, the consumer electronics giant, that will install your EMR using their Geek Squad. So much for needing clinical expertise!

I believe this climate of frenetic activity will cause the EMR market to encounter a large, steep speed bump in the next 10 years. It won’t be from all of the EMR installations or supporting all of these systems, as this will create thousands of jobs and supporting infrastructure that currently does not exist. The bump in the road will come when all of these new digital silos must talk to each other as required in Phase II of Meaningful Use (MU). It is the very selling point of these systems — simple communication and usability — which become the Achilles heel of these EMRs.

EMR’s to date are not installed with a common code structure for identifying exams, studies, or services, all of which will need to be exchanged outside of the office in Phase II of MU. The reason for this lack of standardization has nothing to do with EMR functionality or capability — it is that everyone is still thinking locally not globally.

To ensure true interoperability and exchange of patient health information, EMRs must be installed to satisfy the local requirements, but also with the forethought that they will integrate to larger systems. This requires standards and standardization. The absence of a standard will require the use of translation services so that HIE repositories use the same codes for exams performed across the region.

Translation services, while a viable alternative to standardization, require one-off knowledge for the database structure and logic for each customized local EMR as well as that of the destination repository. This level of granularity creates layers of complexity for maintenance and mapping. Any changes to local system will mandate updates to the translation engine. The support nightmare of constant mapping modifications to assure the proper codes are sent outbound or received inbound will be effectively unsustainable.

Once all of the paper silos are replaced by digital silos, there will be enlightenment of EMRs that were installed incorrectly, don’t address the clinical workflows of the office, and don’t communicate outside of the office with a standard communication protocol using standard coding methods. This will lead to a second phase of the EMR revolution will include translation services and reinstallation of EMRs to address workflow and data gaps. This will have to be resolved before integration to a larger HIE repository can take place.

If we begin now with standardization of workflow and codes and ensure they are addressed with current EMR installations, we will be in a better place in five years and users will see the true benefits of these systems. With our current strategy of “every man for himself,” we risk losing users’ confidence once these systems are installed and address workflow and physician concerns. Once we lose the users’ confidence, they will stop using the system and re-adoption efforts will prove Herculean.

As you begin planning your EMR implementation, there are hundreds of questions to ask. When it comes to meeting the long-term requirements of MU as well as realization of the true benefits of an EMR, here are a few to begin with:

  1. Have we reviewed and documented our office workflow?
  2. Are we using the new SNOMED codes?
  3. Are we following standardized codes for services rendered?
  4. Does the installation team understand clinical workflow or do they look glassy-eyed when we discuss medical terms?
  5. Is our vendor of choice an IT company trying to cash in on the HIT initiative without clinical experience and knowledge which could place our business at risk?
  6. How will this EMR connect us in the future to larger integrated systems?

Jon Shoemaker is senior consultant with Ascendian Healthcare Consulting of Sacramento, CA.

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Currently there are "13 comments" on this Article:

  1. Evan Steele makes one excellent point, but I wish he’d gone further. I don’t think you can lump all of primary care into one EHR basket. OBs and pediatricians (particularly the latter, who aren’t attached to the Medicare teat) have **very** different needs from your classic “primary care” internist or FP. And they have been woefully ignored except by a few small players.

    However, isn’t he also mistaken that KLAS only interviews practices about their running EHRs? IIRC, they will interview anyone about their vendor experience, even after-the-fact. There’s no question that the failed-EHR experience is under-represented in general (someone histalk2.com once interviewed told me that his consulting company stays in business doing eCW de-installs), but I am not sure how much that applies to KLAS.

    Specialty-specific KLAS reports seem like a no-brainer and something they should have figured out on day 1. The worst part? They haven’t even tracked the specialty of their interviewed practices historically, so they can only implement this feature going-forward, if they decide to do it. At least, that’s what the KLAS folks told me.

  2. Irrefutable that many MDs (and vendors profiting from them) think everyone’s goal is”more dollars for doctors” (passed through to them).

    3 CEOs recently promoted adding cost and complexity of separate MD UI or system that duplicates and fragments patient data and shared processes – or suggest yet again making chart a commercial “billboard”. If everyone everyone suffers but MD “gets more dollars” and is “happy”, is that all that matters?

    Can SRS – Allscripts, Cerner, McKesson, Siemens – enable patient-centered, team oriented, optimally safe and efficient, coordinated care delivery and management? How do they support shared problem, med and allergy lists and plans of care with patchwork, hybrid or bolted on MD “systems”? MDs not only one involved in care, and specialist interventions expensive but very small part of lifetime of care.

    SRS has a hybrid hammer, specialists are your nails. Tens of thousands of happy (as docs are today) specialists use Epic – if seriously interested they’re happy to explain value of single system for them and patient. Epic only vendor offering this and good service, hence they dominate market in spite of known product flaws / limitations, green teen installers, arrogant cult-like culture and obscenely high price. Yes, integration and single system lrules.

    Good idea for these CEOs/companies to focus on community docs not in IDN or ACO. While that market literally dying off it won’t disappear. Attempts however to appear “enlightened” sound like thinly veiled self promotion (“more money for us”!). They may believe their own spin, but we don’t.

  3. PeppermintPatty makes some great points, but I do feel some clarification is necessary. “Integration” and “one patient, one record” are just marketing buzzwords for Epic (and apparently people are eating it up). The reality of Epic’s system is that it is a single database with multiple user interfaces to look at the same data. Those user interfaces match the databse workflow, not the user’s workflow. It isn’t integrated with anything, and in fact one of Epic’s serious flaws is that their system integrates with virtually no other products outside of their product. Reality is, they really only have one product. There’s nothing particularly more “patient-centric” about Epic’s EMR than any other EMR, and I challenge anyone to point out significant differences. They say that as a marketing tool just to cover up the deficiency in the fact that they’ve only got one narrow data set to work from. Other systems I’ve seen are built in a way to match departmental workflow and combine all that data – what you might call “integration,” ironically. Sometimes they fall flat in complete integration, but the idea is there and the technology will get there.

    The idea that all specialists, or users in general, are happy with Epic is a flat-out lie. My own academic specialty clinic rebelled against using Epic’s ambulatory interface in our clinic as long as we could, and we switched only by force. It destroyed my clinic workflow, and I now see fewer patients while spending longer documenting as a result. Residents and students in particular, who are used to a higher standard of technology in general, abhor Epic. It’s not just the build at my facility, because when I talk to colleagues at other academic hospitals and at Kaiser, I have yet to meet any doctor who really likes Epic. Most are either ambivalent or negative. Most doctors, by nature, grumble to each other and just figure out work-arounds rather than complain loudly on a large scale. Administrators pump in great KLAS surveys (with certain incentives provided by Epic to do so, from what I hear – rumor*) and the marketplace gets the impression that Epic has hundreds of thousands of satisfied users.

    Epic really is just a marketing machine, nothing more. Hospital administrators seem to be willing to overlook major flaws because they’ve been convinced that Epic is simply as good as it gets, regardless of what else they’re shown. Whatever they’re doing, they’ve got people convinced it’s magic.

  4. Word on the street whispers that the FDA is still taking complaints about EHRs and CPOEs.

    “Epic really is just a marketing machine, nothing more. Hospital administrators seem to be willing to overlook major flaws because they’ve been convinced that Epic is simply as good as it gets, regardless of what else they’re shown. Whatever they’re doing, they’ve got people convinced it’s magic.”

    Thus, if you guys have complaints with adverse events, report them to MedWatch.

  5. Epic as a marketing machine? You’ve got to be kidding. They don’t even have biased bloggers out there slamming HISTalk w/ biased perspectives.

    As far as Evan’s comments on specialists – absolutey – an EMR need specialty specific workflows.

    Systems like Epic’s follow a fairly straightforward approach – similar to what Evan would do as he creates an EMR for multiple specialties. You figure out what specialists have in common and you figure out where they have unique needs. You then program workflows for both of them.

    At any given point in time, as a purchaser, you look at your available options – you weigh the choice between integration and specialty support and you make a choice.

    There is no magic there. Just hard work and it takes people time to do specialites one after another.

    Evan is the marketing machine in this weeks post. Building a case against strong competitors and building a need for his product. At the end of the day though, Evan is on the same road as everyone else. Build computers systems that help users get through their day.

  6. One correction to Evan’s post. He wrote:
    “Many hospitals have had some success with Epic and other hospital-focused EMRs”

    Epic began as an ambulatory EMR with a sweet spot in larger group practices. It is now seen as primarily a hospital EMR, but that is more perception than reality.

  7. Judging by the comments to my post, the implementation of enterprise EMRs in ambulatory practices is a major issue confronting physicians. Most of the comments focus on Epic, the dominant player in that market. Peppermint Patty and Epic Mythology sum up the two positions—the former claims that there are many happy users of Epic, while the latter argues the exact opposite. Who is right? And how do we find out for sure? My experience speaking with thousands of physicians over the years supports Epic Mythology’s position—like him, I have not met any specialists satisfied with using enterprise EMR systems in their private practices.

    Given the revived interest in EMR purchases, it’s critical for the physician community to know the truth.

  8. Evan Steele neglets to say that his product is not really an EMR, just scanning paper charts and calling it an EMR. Since there is no structured text that can be used for analysis or reporting, he evades the questions of meaningful use and quality reporting by saying that they are irrelevant to “busy specialists”, who only care about making money by doing as many procedures as possible in our fee for service world. I beg to differ. I think most docs care about being part of the solution rather than maintaining the stause quo, as represented by Evan Steele.

  9. Epic Mythology and Evan,
    Much appreciate comments. Totally agree Epic not a great product, just better by comparison than a sorry lot because of “integration”. True, many MDs grumble when touting advantages.

    My issues is arrogant insular junior staff and Judy who refuse to hear anything about systems that were better then Epic decades ago. Epic knows best.

    Have heard undercurrents, but perhaps product problems go deeper than even those widely known. CIOs and CEOs paying obscene money not about to volunteer maybe it’s not so great and Epic has some language to prohibit bad PR I believe.

    I’m open to new info but know trying to support team based, patient centered care with a dozen pieces of patient record and interactions glued together with HL7 is not the answer. Interoperability reliant on complex data mapping of multiple ill- defined, poorly adopted and widely adapted standards is not going to work either.

    My claims about Epic related to hospital employed not community MDs. Docs at Kaiser range from haters to wild supporters – would love to see internal satisfaction survey if anyone has it.

    Who will step up in the next replacement cycle to replace Epic?

  10. Cant we all just get along??? I think we all agree nothing is perfect, but neither is the paper chart. I think SRS is perfect for physicians who like to go fast or for ones who do not like to be over burdened with the cost or complexities of a system like EPIC. Many physicians have used SRS as a segway to a traditional EHR. If you’re in academia or an employed physicians where productivity does not matter as much, then EPIC will do. I have worked with both EPIC and SRS and they both have good products, just very different. SRS seems to be very popular among practices de-installing EHRs, which tells me its beating the paper chart by a long shot.

  11. SRS clients, and specialists in general, definitely do want to be part of the solution, and welcome the adoption of EMRs that meet the needs of their respective specialties. Gwendarlingfan has apparently not seen the SRS Hybrid EMR recently, because it contains all the relevant features of what she calls a “real EMR,” including ePrescribing, discrete data capture, reporting, order management, and lab interfaces, all of which capitalize on a more efficient document management system than any other EMR can claim.

    Experience shows that many high-volume specialists simply will not use—or succeed in using—an EMR that is primary care or hospital focused because, as the American Academy of Orthopedic Surgeons states in its recent Position Statement, “The different needs and uses of EHR by disparate medical specialties should be recognized. In particular, the differences between surgical specialties and primary care specialties should be acknowledged.” There needs to be viable EMR options for these physicians.

  12. Evan,

    I would agree that EMRs should be more specialty focused in order for reliable and meaningful use to take place. For example, psychiatrists would not be looking for the same things in an EMR that a general practicitioner would. However, even when EMRs for a doctor’s specialty do exist, it can be very difficult for practitioners to wade through the hundreds of EMRs available to find one that will be especially suited to them.







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