Sunday, April 11, 2010

EHR Mythology 101

Healthcare IT is bustling with activity these days. There are big changes in the air and, only time will tell, but we may be witnessing a defining moment in HIT. Naturally, everybody involved has an opinion and some folks, yours truly included, have more than one.
Below are some of the more popular opinions amongst physicians and a considerable portion of industry analysts.

The current EHRs on the market are outdated legacy systems – This is the battle cry of every new entrant to the market. First the ASP, or web based, vendors referred to the existing client/server vendors as legacy systems. This is about to change once the iPhone EHR vendors start calling the web EHRs legacy systems. One common thing that new vendors tend to gloss over is the fact that the existing vendors did not stop writing software in 1995. Most incumbents are releasing updates and major new versions on a regular basis, and by now most Visual Basic code has been replaced by .NET and the latest Java technologies. True, here and there, you can still find MUMPS platforms, but even the VA’s VistA is in the process of getting a major upgrade towards generic web based capabilities, not to mention the futuristic bombshell veteran EHR vendor e-MDs is about to toss into the mix.

One small reminder to the swooning fans of upcoming iPod/iPhone/iPad EHRs would be that these inevitable iEHRs are nothing more than a return to a closed platform proprietary (OS and hardware) client/server paradigm, when compared to platform agnostic applications like athena Clinicals, Practice Fusion, Ingenix Care Tracker or many other pure browser based offerings which can be accessed across the globe without having to purchase a specific brand of computer and without having to download a bunch of proprietary software first and without having to obtain permission to develop the product to start with.

EHR prices are small fortunes – You can buy, or subscribe to, the top of the market, eClinicalWorks EHR for $250 per physician per month. You can subscribe to Practice Fusion’s EHR for FREE. You can get Amazing Charts for less than $150 per physician per month, including the Practice Management system with the most expensive interface costing $500, and most are free. I spend more than that on Starbucks. True, if you need new computers, you will need to spend more money, but I have not heard of any futuristic EHR slated to run without hardware. Also true, there are some very expensive EHRs out there. The Bugatti Veyron sells for $1,700,000. Does that mean that cars are unaffordable? Do you even want a Bugatti? I don’t know, but I couldn’t fit my kids and dog into one of those, so I’d rather drive a Jeep.

EHR implementations fail because the software is unusable – True, implementations do fail and by fail I mean everything from throwing the vendor out to using only a small portion of the product. The question is why do they fail? Before answering that, let’s note that most implementations do not fail. Implementation failure is not limited to certain EHRs or certain specialties or certain practice sizes or certain demographic groups. It has been linked however to lack of change management, poor choice of product, wrong expectations, insufficient training, lack of commitment and all sorts of peripheral lack of preparedness. If EHRs should be as easy as driving a car, then everybody should have to take Drivers Ed. or log 200 hours of supervised driving before taking the Bugatti to the Autobahn or even to LA during rush hour.

CCHIT certification doesn’t mean anything – True, CCHIT is not an ONC approved certification body at this time, but it will most definitely be as soon as ONC approves any certification authority. 2008 CCHIT certified EHRs are very close to being able to qualify for HITECH incentives and 2011 CCHIT ARRA certified software is perfectly adequate. Considering the ONC certification plans, it is expected that multiple certifying authorities will come into existence, which is not the same as saying that CCHIT will become irrelevant. It will just have some well-deserved company. Also true, there are several smaller EHRs that have no CCHIT certification and are fully capable of qualifying for the upcoming ONC certification and they may very well apply for certification.

EHRs should be like Facebook – Social media is the hottest kid on the block. Everybody tweets, blogs and writes on other people’s walls. We have laptops, netbooks and smart phones and we are always connected to each other. I know someone who tweets in the shower. The logical conclusion must be that consumers should be able to access their EHR from the bathtub and post updates to the provider’s wall, or maybe the other way around. True, both patients and physicians should be able to access medical records from any location, but most EHR work is, and always will be, performed in a clinical setting. EHRs are tools for providing health care. For care providers EHRs are tools of the trade, not much different than CAD tools are for engineers and Visual Studio is for developers and QuickBooks is for accountants. For patients, EHRs are tools to manage health status or chronic disease, maybe a bit similar to paying bills and preparing taxes online. Nobody needs to access TurboTax in the shower.

EHRs should be about Clinical care not Billing – True, most EHRs contain coding advice and even automated E&M calculators. Most template-based EHRs go to great lengths to facilitate documentation as required by CMS to justify a particular level of reimbursement. However, as any EHR user will attest, EHRs do not force users to create convoluted, billing-justifying documentation. So why do physicians keep creating such documentation while complaining of how terrible the notes look? Probably it is because, at the end of the day, every doctor wants to get reimbursed adequately for his/her work. EHRs did not invent our reimbursement system. CMS did. EHRs are tools designed to reflect reality not utopia.

Big monolithic EHR products are bad – Modular vs. monolithic software development is an old controversy dating back to the large kernels vs. microkernels debate. In the EHR context, the single vendor vs. best of breed argument has been going back and forth since hospitals started installing MUMPS based systems. At least for hospitals, it seems that Epic has put the argument to rest in favor of the single vendor approach for EHR. For small practices, with practically nonexistent IT expertise, aggregating and integrating and supporting an array of software modules from different manufacturers, with no guarantees of ability to integrate them, may prove to be a very frustrating money pit.

Unless you are a computer whiz kid, you don’t usually go to a computer supply store and buy a motherboard and a case and a hard drive and video and sound cards and all sorts of paraphernalia to take home and assemble your laptop. You go to BestBuy and buy a Dell. Granted Dell, didn’t make all the laptop innards, but instead assembled them much like the whiz kid did, but you don’t care and you don’t need to worry about it, because if your Dell breaks, Dell will fix it, no matter who manufactured the capacitors on the motherboard.

As to the end product assembled from simple little modules, I think what Linus Torvalds, the colorful creator of the utmost open platform, Linux, said about microkernels applies very well to our discussion:

"The fact that each individual piece is simple and secure does not make the aggregate either simple or secure."

Physicians should wait until the perfect EHR is ready – Let me go out on a limb and make one prediction here: Unless the Almighty creates an EHR for us, perfection will never be attained. Large hospitals and large physician groups are buying EHRs and are getting connected. If small practices have any chance at survival in our quickly transforming health care environment, they must find ways to increase efficiency and they must be able to participate in the soon to be mandated information exchange. Whether the canteen is half full or half empty depends on how dehydrated you are. Pouring the water in the sand because you are seeing a vision of lush palm trees and waterfalls on the horizon may not be the wisest decision you can make.


  1. Brava, Margalit, brava: these are excellent points that everyone in the HIT jungle should read. The quote from the great Penguin himself is especially pertinent, given the certification IFR's treatment of EHR modules:

    "... this approach carries with it a responsibility on the part of the eligible professional or eligible hospital to perform additional diligence to ensure that the certified EHR Modules selected are capable of working together to support the achievement of meaningful use."

    Thanks for such a practical approach to the EHR hoopla, which will probably only get crazier as HITECH progresses. In answer to point number two, I'll admit as a budget compact driver that I don't even know what a Bugatti is. I think a lot of doctors feel the same way: they want something that will safely, efficiently work; at least as safely and efficiently as can be reasonablly expected outside of utopia, which all should remember is translated correctly to "no place."

  2. Thank you, Michelle.
    I agree that this HITECH induced hoopla is not about to subside any time soon. At least not as long as there is still more money to be distributed.
    That quote you posted up there is the stuff of nightmares. I am half hoping that nobody will develop any modules, but they probably will...

    There are good compact solutions out there that would take any small practice from point A to point B, but we just keep chasing after the "better mouse trap". Not sure if it qualifies as innovation.

  3. Margalit,
    Thank you for beginning the discussion to dispel misconceptions that vendors, buyers and patients have about EMRs/EHRs/PHRs . There are several concepts that I believe may require elaboration.

    First, EMR software is sold like any other software available for the commercial market. Either the vendor has a complete product and users only access 20% of its features, or the product is sold with only 70% of the advertised features completed. Practically, software installations are not seamless and fail because of the limits of customer infrastructure or IT talent -- subjects not gauged sufficiently when the sale is made (see my blog post on at

    Second, EMR and back office software shifts much of the responsibility for ensuring appropriate reimbursement and performance auditing to the provider and their staff, creating a cost burden that is unsustainable. The issue of matching clinical data to meet the varying requirements of reimbursement is fostered not by clinician prerogative, but the unwieldy proprietary workflow process that fiscal intermediaries place upon the provider. Medical providers believe that workflow processes -- such as checking eligibility and submitting claims -- and prudent clinical work should be reimbursed. For-profit commercial medical plans make decisions on medical care based on pre-set contractual reimbursements rather than what is necessary for patient care. This combination makes EMR design unwieldy as it tries to satisfy divergent goals.

    Lastly, social networking need not be an integral part of the EMR design. However, social networking can play a key role in helping doctors manage their patients better and that objective should be the goal of EMR vendors. At this time, few vendors seem to recognize the benefits of this social movement.

    In summary, your blog post is a great starting point for further discussion, and I hope it will perk up vendor ears as well as user ears. The software has to be marketed with more than short-term business objectives. It must appeal to the whole health care value chain – including the goal of optimal patient care.

    Richard Hom
    On Twitter “GrandRounds4ODs”

  4. Dr. Hom,
    Thank you for the thoughtful comments. I read your article referenced here and I do agree with most points. Unfortunately, the "colorful" sales methods prevalent amongst EHR vendors are nothing to be proud of.

    All that said, we need to remember that EHRs are nothing but software tools. Nothing more. They can help with the practice of medicine, particularly the business part, but they cannot counteract the regulatory and reimbursement system. We need to change policy and EHRs will follow in a heartbeat.

    As to social media, I do agree that EHRs can vastly improve on their current capabilities and most vendors are not paying much attention to the social aspect. That is why I pointed out in an earlier post here (, that creating a community around one's practice is a rather simple thing to do.

    I hope the changes taking place now both in the HIT world and the HC policy environment, will bring us closer to creating more and better value for patients.

  5. Yeah! True, both patients and physicians should be able to access medical records from any location, but most EHR work is, and always will be, performed in a clinical setting. EHRs are tools for providing health care. They use it to make their everyday task make more easier. Anyway, thanks for sharing this useful information. Looking forward for your next post.


  6. All that said, we need to remember that EHRs are nothing but software tools.
    Eligible hospital to perform additional diligence to ensure that the certified EHR Modules selected are capable of working together to support the achievement of meaningful use."