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February 8, 2010 Readers Write 14 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!

First Impressions of the iPad in Healthcare
By Trey Lauderdale


I don’t think we have ever seen a piece of technology as polarizing as the recently released Apple iPad. Being vice president of innovation at a healthcare-focused iPhone development company, I have received an unbelievable amount of feedback (some solicited, some not) on the good, the bad, and the ugly of the iPad’s potential uses in healthcare.

The first potential use models are the usual suspects we have all been hearing about for the last 3-6 months: entering data into the EMR, viewing medical images, observing patient data, managing alarms and alerts, etc, etc, etc. I could go on and on, but you already know all of these because they are available right now on your iPhone.

Don’t get me wrong — all of these functions are wonderful, but nothing here is really game-changing. I consider these the foundation of what is necessary to bring this device into healthcare in a useful manner.

In my opinion, the greatest impact this platform will have on healthcare is going to be from the creative juices squeezed out of the developer’s minds who will be writing applications specifically geared for the iPad and its potential use model.

You have got to look beyond version 1.0 of the iPad and into what it will become in the second, third, and onward generations of the device / platform. Apple tends to make significant improvements to their product between the first and second generation releases (2nd Gen iPhone >> 1st Gen iPhone). The limitations that have been brought up are all valid, but will be alleviated over time or through simple physical remedies.

It won’t survive in the hospital environment?

A robust, antimicrobial case will be out by the end of 2010 – it can almost be guaranteed.

No camera for image taking?

It will be there by Gen 2 (not for healthcare, but because consumers want it).

Too big to fit in a pocket?

The workflow model should not position this as an “always carried” device.

The one limitation that had me on the verge of throwing my MacBook across the office was the lack of background processing. While potentially the greatest shortcoming of the iPad, after some thought and analysis, it needs to be viewed as a mixed blessing. This device is going to have 1GHz of processing power focused on ONE application. The user experience in the currently open application is going to be amazing, assuming developers take time to re-factor their applications to fully leverage this “limitation.”

Through appropriate use of inter-app communication and data sharing, a great deal of the concerns brought on by no backgrounding can be bridged relatively easily. The key is going to be the foundational applications leveraging and creating open-source frameworks and standards that can be leveraged across multiple vendors in a collaborative environment.

The first day the iPad is released in March, all of the technology and applications are in place to enable a caregiver to view their patient’s vital monitoring waveform (Airstrip Technology), check the data against their EMR (Epic Haiku), and then send a quick message to an appropriate staff member asking them to take action on a potential event (Voalté).

While these currently reside as three separate applications, the experience provided to the end-user should not feel as such. The real power of the iPad (and even iPhone) platform is going to be a collaborative environment between the vendors that reside on the device. This collaboration will be of even greater importance with the iPad due to the greater amount of real estate the end user has to work with.

I can envision a hospital where an iPad is placed outside every hospital room displaying relevant information about the patient and their current vitals (REALLY decentralized monitoring). Clinicians grab the iPad as they enter the room, sign in with a quick series of hand gestures (or maybe take a quick picture of their ID?), and easily enter information into the open application regarding the patient’s current status. Messages and tasks can be dispatched to the right caregiver automatically from the iPad, and the clinician places the device back into the cradle once done with the patient. All of the pieces for this experience are currently in-place and ready to be tied together.

Apple has provided the revolutionary platform we could have only dreamed of 10 years ago. It is now our responsibility as application developers and IT system administrators to turn those dreams into reality and provide the end user experience our clinicians deserve.

Trey Lauderdale is vice president of innovation of Voalté of Sarasota, FL.

Interim is not Final
By Mountain Man

I don’t know about you, but my organization is asking a lot of questions about ARRA "now that it is finalized" and what we as an organization should do. Should we change our strategic plan? 

With all the hype and media around this pseudo-event, we certainly have the the eyes and ears of our executive team and board members. We have somewhat of a bully pulpit. We should use the awareness created to advance our causes of bringing safety and efficiencies to healthcare delivery and financial visibility  into the business. If we can tilt the spending towards an appropriate amount in order to complete our strategic plan, we should do so.

Here is the problem. “Interim” is defined by Wikipedia as “a temporary pause in a line of succession or event.” This does not sound very FINAL to me. So, Interim Final Rule really makes little sense.

Quit freaking out, people. NO ONE thinks we can hit the dates provided by the IFR. We should not reallocate all our resources to cover some part of the ARRA requirements that we left out of our strategic plans two years ago.

Most of us are working towards the general direction that the IFR is leading us. Keep doing what you are doing. Trust your plan and execute.

It is your STRATEGIC plan for a reason. Hitting an INTERIM suggested state is very TACTICAL and short-sighted.

If you are not headed in that general direction by now, then you should freak out.

They’re all Synonyms!
By Deborah Kohn


I don’t know how many times I delivered a presentation / authored a published article when I had to explain why two healthcare information technology (HIT) trade organizations (one so large that it won’t be mentioned in this article and the other, federally commissioned at taxpayer expense and no longer in existence) adopted definition differences between an electronic medical record (EMR) and an electronic health record (EHR).

This only further confused my healthcare professional audience / readership who, for years, have had a complete understanding that charts, records, patient charts, patient records, medical records, health records, etc. are synonyms! Walk into any hospital or clinician office and always one will hear an assortment of such synonyms without ever questioning the meanings.

True, in the late 20th century, synonyms of adjectives, such as computer, computerized, automated, or electronic were needed to differentiate between (what is known in the greater IT world as) analog vs. digital charts, records, patient charts, patient records, medical records, health records, etc. However, still the use of the synonyms of adjectives with the synonyms of nouns made no difference to practicing healthcare professionals, except to differentiate, when necessary, between analog, digital, or hybrid.

Thankfully, we might be getting close to ending this nonsense. Recently, one HIStalk reader correctly pointed out that NOWHERE in the 2009 American Recovery and Reinvestment Act (ARRA) with its Health Information Technology for Economic and Clinical Health (HITECH) Act is there a distinction made between an EMR and an EHR. Only the term electronic health record and acronym EHR is used — for health information exchanges, for hospitals, for physician offices. That’s probably because every healthcare industry-bred author / reader / interpreter of this legislation has a complete understanding of what is being conveyed.

On the floors or in clinic rooms, let’s continue to use whatever synonyms (adjectives and nouns) come to mind, because we’ll continue to understand what is being communicated. In addition, let’s give credit to the 2009 legislation for dealing one of the final blows to this “trade organization made up EHR/EMR” definition debate and all agree to use EHR (as used in the ARRA / HITECH legislation) as the standard terminology in presentations / published articles / vendor products, etc. Only then will we be able to move on to more important discussions.

Deborah Kohn is a principal with Dak Systems Consulting  of San Mateo, CA.

Licensing of EHR Systems: Contractual Considerations
By Robert Doe, JD


As a result of the incentive payments offered under the HITECH Act for implementing certain qualifying EHR systems, many healthcare entities are evaluating the various EHR systems that are available, taking into account the certification, interoperability, and meaningful use requirements. There are a number of considerations a healthcare organization should take into account during the process of choosing and contracting with an EHR vendor.

A healthcare organization should consider including certain warranties and representations in the agreement with the EHR vendor to help ensure that the system is capable of allowing the healthcare organization to receive the incentives (and avoid future penalties) associated with the adoption of an EHR on an ongoing basis for the term of the license. As a drafter and negotiator of license agreements on behalf of healthcare organizations, while some vendors claim to do so, I have seen reluctance on the part of EHR vendors to meaningfully warranty their systems with regard to these considerations.

One argument is that the criteria for receiving the incentive payments have not been clearly defined. Future requirements, the argument goes, could conceivably require significant investment in new functionality. In addition, a vendor may argue that it has no control over how the system is actually used within the healthcare organization.

With regard to the first argument, EHR vendors are receiving significant new business as a result of the HITECH Act. If they cannot warrant the functionality which is one of the main motivating factors for licensing the particular system chosen, they are in effect transferring the entire risk to the healthcare organization, which, at a minimum, should be shared by the parties. For a significant capital expenditure of this nature, care should be taken to produce the result which justifies the expenditure. As a result, this should be one of the first discussions a healthcare organization should have with the EHR vendor during contract negotiations.

Some vendors may offer warranty language that appears to address the subject matter, but from a legal perspective, doesn’t actually provide much in the way of legal rights. Some vendors may propose that the issue be addressed as part of maintenance and support. Keep in mind that the legal remedies may be significantly less for a breach of maintenance and support as opposed to a breach of warranty. The warranty language could also be crafted to take into account the situation where significant additional investment is required for the system to conform to HITECH’s requirements, allocating an agreed upon portion of the expense to the existing customer base.

With regard to the second argument, it’s true the vendor has no control over how the system is actually used by the healthcare organization, but the warranty language can be worded to ensure the system includes the necessary functionality to allow the healthcare organization to qualify for incentive payments and avoid future penalties.

In addition, many healthcare organizations are endeavoring to provide access to their EHR systems to other unrelated healthcare organization in their communities, as part of a regional health information organization, health information exchange, or otherwise. The underlying goal of many of these arrangements is to provide EHR technology to other local healthcare facilities that may not be able to afford such systems by themselves. Such arrangements may also help to lesson the financial burden. Whatever the reason, there are legal and licensing issues to consider.

Any healthcare organization that desires to provide access to a software application to another unrelated healthcare entity or clinician must be aware of the physician self referral prohibition (Section 1877 of the Social Security Act) commonly known as the Stark law, the federal anti-kickback statute, and, depending on the data being exchanged, the Health Insurance Portability and Accountability Act, commonly known as HIPAA. In addition, significant anti-trust issues could arise if the software allows the sublicensees to share financial information. These additional legal issues must be addressed with legal counsel prior to setting up such an access arrangement.

In addition, the agreement with the EHR vendor must contain specific provisions allowing the healthcare organization to provide access to the unrelated healthcare organization. Do not assume that you can provide access by simply executing the EHR vendor’s standard form license agreement. All license agreements contain a license grant section that specifies the parties and individuals that can use the software. In most instances, it is limited to employees of the legal entity that signs the contract.

In addition, most license agreements specifically prohibit the use of the software to process information for, or use the software on the behalf of, any third party. The contractual language allowing the healthcare organization to provide access to an unrelated organization can take many forms. It may be as simple as expanding the definition of an authorized software user to include any other individuals authorized to use the software. Alternatively, the license grant may specifically state that the licensee may sublicense or provide access to the software application to a third party and set forth the conditions under which it can do so. There will also need to be an agreement between the two healthcare organizations governing access to and use of the EHR system. Careful consideration should be put into the drafting of this document. There are a number of issues that could arise if not addressed in this agreement.

The HITECH Act incentives have increased demand for EHR systems. Often times the timeframe for implementing such systems is quicker than would ordinarily be the case. It has been my experience that taking the time now to address the legal and business issues will help avoid problems in the future.

Bob Doe is a founding member of BSSD, an information technology law firm located in Minneapolis, MN.

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Currently there are "14 comments" on this Article:

  1. Regarding Synonyms.

    Before this issue of HISTALK I believed in my definitions. These are not my definitions, but those outlined by HHS (Sorry, my link to the article is broken and as relevant as an EMR without HIE!  http://www.hhs.gov/healthit/documents/m20080603/10_2_hit_terms.pdf)

    The principal difference between an EMR and an EHR is HIE. An EMR aligns with the prevailing state of electronic records today. The industry is rapidly moving toward electronic records capable of using nationally recognized interoperability standards, which is the key defining component of an EHR. With the passage of time, electronic records without HIE will be irrelevant. .

    Thus the term EMR is on course for eventual retirement.

    • EMR – An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.

    • E H R – An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.

    Did I get something wrong here?

  2. RE: First Impressions of the iPad in Healthcare

    “In my opinion, the greatest impact this platform will have on healthcare is going to be from the creative juices squeezed out of the developer’s minds who will be writing applications specifically geared for the iPad and its potential use model.”

    Most of what has come out of developer’s minds for the past several years have been doing exactly what you are envisioning. Writing apps geared toward the technology and not geared toward the clinician. And that’s the problem. Lots of bells and whistles and apps that look really cool, but are burdensome to the clinicians who are forced to use them. We have enough of those applications in circulation.

    “Apple has provided the revolutionary platform we could have only dreamed of 10 years ago. ”

    Really? You must be new to healthcare IT.

  3. Re: Greg Park’s comments on EMR vs EHR:

    Sometimes semantics take on a life of their own. Trash Collector vs. Sanitation Engineer. Used Car vs Pre-owned Vehicle. Obese vs. weight-challenged. Pet Project Funding Allocations…vs. Earmarks.

    Euphemism has become a common trick to make something more presentable than it essentially is. Making something sound better doesn’t actually make it different….or better.

    Is there an industry standard definition of EHR vs. EMR? Who has the right to set the actual difference? Vendors? Some consultant? IEEE certainly hasn’t. The Government obviously hasn’t. What is it…somebody’s conventional wisdom makes it so? Cite your source, Mr Park.

    The interoperability Mr. Park so embraces does not exist…yet…perhaps ever. No product out there can claim any sense of true interoperability right now…except closed-loop systems in captive medical enterprises. Go outside that closed-loop system…there is no system. Send the fax. Email it. Nothing that fits the seminal “EHR” definition Mr. Park says with so much conviction exists.

    So, in a now-familiar phrase, “Who Dat…” that says there is anything more to the difference between EMR and EHR than Ms. Kohn says…their just synonyms.

  4. “Really? You must be new to healthcare IT.”

    In the year 2000 we had barely even heard the term google or facebook, linkedin, we didn’t have any true concept of how all consuming web technology would become by 2010. While I don’t believe Apple has done anything spectacularly new (Download.com/cnet has provided cheap software tailored for specific systems for years) it hardly needs to be new to be revolutionary.

    Webster defines Revoliutionary as: c : constituting or bringing about a major or fundamental change.

    Trey obviously believes this to be the case with the ipad. I’m refraining from weighing in until I have a chance to use the product but with its pricepoints Apple is certainly making what appears to be a quality tablet available to the general public and may well be opening the door for a tablet revolution. Personally I used my first tablet around 2000 and found it novel and fun to play with but inefficient for my purposes. Regardless, Viva La Healthcare Revolution

  5. Re: Licensing of EHR Systems: Contractual Considerations
    By Robert Doe, JD
    Having “lived” as both a provider and a vendor, I can appreciate the precise language recommendations made by Mr. Doe. However, what is apparent (and not unusual coming from a JD) is the complete lack of knowledge of the business implications of such language to, in effect, guarantee the ability of the provider to earn the Meaningful Use dollars.
    Such a guarantee would require a contingent liability on the books of the vendor equal to an amount of the entire anticipated award to the provider over the course of the contract, most of which auto-renew and are, therefore, limitless. Because the interim final rule is just that, interim, no one knows for sure the size of the stated liability. One could be fairly certain that the GAAP ruling would be to hold in reserve an amount equal to the total award and just diminish it over time as the awards are earned by the provider. This, in effect, negates the sale and would not allow recognition of revenue until the awards are earned by the provider. Setting aside the cost of audits to manage these huge contingent liabilities, one can only imagine the VERY negative impact such reserves would have on balance sheets, earnings and stock prices for the large, publicly owned companies and the stated net worth of private firms. Simply stated, it would be a disaster and is an unreasonable expectation!

  6. Nurses have been waiting a long time for a tablet with good usability. It’s size and shape might be OK, but how will it stand up to a patients incontinence or a drop on the floor. Where’s the handle or carry strap? It will also need to be equipped with bar coding technologies for medication administration and identification of patients and staff. Are you listening Apple?
    How popular this device will be in the future is all speculation from my point of view……Nurses love their I phones, I suggest trying a nurse on the design team..

  7. RE: iPad in Healthcare. I mean the following in the kindest possible way from a clinician’s perspective, and particularly Nursing: your development team needs to spend quality time shadowing them. You have the unbelievable good fortune of having Sarasota Memorial in your back yard and what by press accounts was a great pilot with them last year…while Denis is great at making things happen on the tech side, please get together with Gwen and Jan to seal a deal for access to the staff and clinical area…from the few things said here, it is clear the iPad and related technology are nothing compared to overcoming the lack of knowledge on how to leverage it in the clinical area, unless you are purposely trying to throw the competition off the trail and not that there would be anything wrong with that… (Also, I mean no disrespect to Dr. Korniewicz and what her expertise has contributed to bringing your company so far in such a short time – kudos on all the accomplishments to date!). Wishing you all the best on the journey of discovery and would be great to hear an update in 6 months or a year as the reality sinks in of what is involved in merging the latest hot technology, legacy systems/hdw, spending constraints, and clinician needs circa 2010. As a certain beer company located just up the road from you in Tampa said during the Super Bowl – here we go.

  8. Don’t let the FDA know you’re planning on displaying waveforms and ‘real time’ vital signs on your iPad – Apple will be sucked into the black hole of medical device regulation

  9. EMR vs EHR – the old paradigm endures. They both describe an electronic version of a paper record that exists in a silo. The new paradigm envisions a patient care plan that exist virtually. All data that is captured relates directly to the patient’s specific health conditions. The description of the iPhone sitting in the patient’s hospital room provides a glimpse of how such a virtual care plan could be accessed.

  10. Re: EMR vs. EHR:

    There comes a point when terms have been so misused and so misunderstood, that they should be abandoned or replaced.

    Another one of those terms: “informatics.”

  11. Cynical_Informaticist Says:
    Don’t let the FDA know you’re planning on displaying waveforms and ‘real time’ vital signs on your iPad – Apple will be sucked into the black hole of medical device regulation

    Not sure if you are cynical about iPad, or cynical about regulation. If the former, well that’s appropriate.

    If the latter, I have a syphilis experiment I’m planning and I need a collaborator.

  12. EMR vendors and Fun with HIT history:

    PM systems and Y2K. Enter, EMR/EHR’s. Integrated or Interoperable? There is no difference if someone bothers to poll our physicians. RHIO’s gave way to IPA’s and morphed into HIEs. Sarbanes-Oxley. CCHIT may be a future retired King of the Hill.

    Now: PC’s, tablets, or iPad? ASP vs. Client server? Hey, won’t Open Source save me money? Why does This guy want $50K per physician, and the other wants $500 a month for all of us?

    All of this HITECH process is like the weather in Texas: If you don’t like it, just wait a minute.

  13. Oh my god…ok my source was clearly indicated in my response. As I said this is NOT my definition but the definition created by the HHS!

    And next time? Call me Greg! 🙂

  14. Re: Greg Park’s comments

    As I tried to convey (but apparently I didn’t) in my article (see above), unfortunately, the definitions for EMR and EHR were not created by HHS.

    A few years ago (can’t remember exactly when) the two separate definitions (one for EHR, one for EMR) were created by HIMSS Analytics — to suit their data gathering needs. HIMSS Analytics is a division of HIMSS, the “large” trade organization to which I was referring in my article.

    In 2008, ONC funded (i.e., federally-funded, at taxpayer expense) a project to provide “consensus-based” definitions for 6 HIT terms — EHR, EMR, PHR, HIE, HIO and RHIO. The National Alliance for Health Information Technology (NAHIT) was chosen to manage this project. NAHIT was the other trade organization to which I was referring in my article. Most of the members of the NAHIT-managed group who huddled to define these terms represented other trade organizations, such as HIMSS. And, once again, the same, two, separate definitions of EHR and EMR that HIMSS Analytics had been promoting were recommended by NAHIT. A year later, NAHIT ended all its operations.

    Because of the NAHIT recommendations (provided to ONC in a report entitled “Defining Key HIT Terms”), HHS, other federal and national organizations, vendors, providers, journalists, etc., ACCEPTED (not created) these two, separate definitions.

    Another point I tried to convey in my article (but apparently I didn’t), was that, interestingly, NOWHERE in the ARRA / HITECH legislation is there mention of the “EMR” — only the “EHR.” In response to one of his readers who noted this, I believe Mr.HISTalk when he wrote that the use only of the term “EHR” in the legislation probably was because (and based on the ACCEPTED, two separate definitions) EMRs have not conformed to nationally recognized interoperability standards, but EHRs have conformed.

    Since I’m a healthcare professional who, along with so many of my healthcare professional colleagues believes that all these terms are nothing more than synonymous nouns and adjectives, I support using the term EHR “as is”, because (and not necessarily in this order) 1) ARRA / HITECH adopted it; and, 2) perhaps our industry can finally cease this debate over synonyms that were codified by trade organizations to suit their needs and not the needs of healthcare professionals!

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