EHR Adoption is Like Treating Cancer

EHRs are not ready for prime time. EHR benefits are questionable and there are documented instances where patients’ deaths were directly attributed to an EHR. EHRs are cumbersome and slow. They are unnecessarily complex and built on very old technology. The people who build EHRs have no concern for the end user and therefore EHR usability is pretty abysmal. And EHRs are expensive to buy and expensive to maintain, not to mention that they can completely derail your practice through loss of productivity. The fact that some users seem to do well with their EHRs, and even derive some joy from using them, is not a valid counter argument since most users are not so fortunate and through no fault of their own. There really is no excuse for such failure in this day and age. Just look at the iPad and the iPhone. You can walk into any Apple store and 5 minutes later walk out with a fully functional product with a delightful, intuitive interface, loaded with hundreds of interchangeable apps that even a three year old can use right out of the box. All for a few hundred bucks.

If you happen to be diagnosed with cancer, you will most likely be subjected to years of unpleasant treatments. You will be injected with poison and irradiated with more poison. You will lose your hair, suffer bouts of vomiting and diarrhea and be physically debilitated to the point where you cannot leave your bed. You will most likely have to go through painful surgeries, take all sorts of medications that were shown to kill thousands of rodents and never recover your old self again. And this entire ordeal will cost you a medium size fortune. The fact that some lucky patients go on to win the Tour de France is not really an acceptable rebuttal. Most do not. And there really is no excuse for such incompetence in this day and age when one little pill can cure you of an yeast infection in 24 hours and a $4 course of antibiotics will render you as good as new if you happen to develop a sinus infection. Not to mention the innumerable vaccines that will miraculously prevent you from contracting the plague.

Yes, this is a farfetched analogy, but replacing paper charts with an EHR is not like playing Angry Birds, and if you want a fair chance at survival, you have to tolerate the side effects imposed by the current state of technology. Just like you cannot postpone your cancer treatment until the doctor from Star Trek figures it all out, you cannot postpone transition to EHR until EHRs are “ready for prime time”.  And make no mistake, in today’s reality, paper charts are as big a threat to the survival of an independent medical practice, as any garden variety cancer is to a human body. Paper charts will gradually and irreversibly deprive your practice from the nutrients and oxygen needed for survival, i.e. reimbursement, until it shrivels and dies, or it gets absorbed into a larger organism. The common wisdom seems to favor these outcomes. I do not. If you are one of the fewer and fewer physicians who has no desire to either shrivel or practice Wal-Mart medicine, here is one way to think about your current EHR predicament. [Note: Considering the gravity of the situation, you would be well advised to seek a second opinion.]

Diagnosis – Look around you. EHRs are slowly gaining ground. You would be hard pressed to find a medical group of significant size that does not have one. Data collection is not as voluntary as it is being portrayed, unless of course you think that you are overpaid and can easily absorb cuts in reimbursement. You can choose to make believe that this too shall pass and once Obama is no longer calling the White House home, all will be as it was. Alas, computerization of medical records has bipartisan support, and it always did, due to a rare alignment of powerful financial interests and progressive ideology. If you want to continue the practice of medicine, you will need to use the tools of the trade. For better or worse, both the trade and its tools are being redefined. Barring a global disaster, the chances of spontaneous remission are nil.

Staging – How bad is it doc? Well, it won’t kill you tomorrow, but the longer you wait, the harder and more expensive it will become, the fewer the choices and the lower the chances of a good outcome. Both public and private payers are experimenting with new reimbursement methods. These pilots, or projects, are cropping up everywhere, supported by grants and all sorts of tax payer monies. The goals may be different and the rules of engagement are certainly different, but these arrangements have one thing in common. They all prefer that you generate and consume large amounts of clinical data in electronic format. You will need an EHR for that.

Treatment – A physician-centered approach to the problem suggests that you should be informed of your options and allowed to make a decision based on your personal and cultural preferences. Since medical practices are not people, you may choose to euthanize your practice. This may make perfect sense if your practice had a long and productive life and your medical career is in its twilight years anyway. A less terminal option would be to allow your practice to be hooked up to the machinery available in large health systems. You will still have to use an EHR, but your new employer will undertake the mitigation of most side effects. There is a slim chance that someday you may be able to remove the tubes and resume private practice, but while your medical career can survive indefinitely, your practice as you know it now is not likely to recover. Or you could make a stand and fight for your independence.

Prognosis – By definition there could be no blinded trials for EHR utilization, and by omission there are no randomized control trial results to learn from. The anecdotal evidence suggests that many thousands of physicians in independent practice are surviving just fine after EHR implementation. Some would say that they are doing better than ever now, and others have resigned to the new ways of doing business. For most, the life threatening problem has been transformed into a manageable chronic condition. It must be noted however, that a significant number of physicians is currently in need of life-support from health systems and hospitals, and many of these are post EHR implementation. We cannot be certain, since there is almost no literature on the subject, but it is highly probable that practices suffering from a relapse have had multiple comorbidities to start with and/or developed other life threatening conditions since. There are no guarantees of course, but if you have an otherwise healthy practice, a positive outlook and a supportive environment, chances are good that transition to EHR now will enable your independent practice to survive and thrive for many years to come. And the opposite is also true.

EHR Bargains Review – Practice Fusion

(Survival Tips for Small Practices)

If you subscribe to Prof. Clayton Christensen’s theories of innovation, Practice Fusion is to the EHR industry what Southwest Airlines was to the air travel industry, ad extremis, with no thrills, no frills and no peanuts. Practice Fusion is completely and truly free to users, and it will take you from point A to point B in a straight and short line, with point A being paper charts and point B being a Meaningful Use incentive check.

The Model

Practice Fusion is a web-based EHR and it is free to use no matter who you are. The company website has a self-provisioning button where any visitor can sign up for a free account and immediately start using the software. All you need is a valid email address. The company prides itself in taking users live on the EHR in 5 minutes. It actually takes much less than 5 minutes to get to a point where you can begin charting, but it takes a week or more to hook up to electronic prescribing and lab interfaces, and this is very much in line with industry practice. Practice Fusion offers free connectivity to national reference labs and a handful of regional ones as well. Just like there are no charges for electronic prescribing, there are no interface fees for the currently available lab connections and no mention of “custom” interfaces built for a fee. You get only what you see.

Since we all know that there is no free lunch, how is it possible to get a free EHR, including significant interoperability? The standard answer to this is that Practice Fusion is ad supported. Just like you get free email services from Google in return for agreeing to see ads on every email page, when you sign up for Practice Fusion, you are agreeing to see ads on every EHR page. To my pleasant surprise, the ads are mostly limited to about one inch of space at the bottom of the screen, and are not at all intrusive in the workflow. I actually don’t quite see how these ads support anything, since with the exception of one Dell advertisement they all seem to be Practice Fusion self-promotions. Furthermore, the fairly new Patient Fusion portal displays no ads at all. Similar to most other EHRs, the Practice Fusion end user agreement reserves the right for the vendor to aggregate and monetize EHR data, and perhaps this is a possible explanation for this free lunch.

Functionality

The best description for Practice Fusion’s functionality is bare-bones. There is no fluff, no bells and no whistles to be found in the very simple, very clean user interface. After muddling through a variety of top-shelf EHRs with double and triple menu-bars and icon studded task-bars on every page, the Spartan look & feel of Practice Fusion is quite refreshing. Although there are multiple training aids in the system, if you are an average computer user (e.g. email, Word), you should not need much coaching to become productive at very short notice. This of course eliminates another hefty expense associated with EHR adoption: training.

Whatever free-form stuff you are now doing on paper, you can do in Practice Fusion, pretty much the same way. It comes with a simple set of SOAP templates consisting mostly of questions where you get to type in the free text response. You can also type directly into the note and probably use Dragon as well. You can create your own sets of questions, or add to existing ones. You can order meds, labs and imaging and print those, or send electronically if connected. Scanned documents can be uploaded to any particular chart. There is no clinical content available for decision support, at this time. Registry functions are in their infancy and the handful of available reports is very simplistic. Disappointingly, the Meaningful Use report does not automatically calculate numerators and denominators for core and menu items, but clinical quality reporting is automated. There is very little customization possible and none is required.

For patients, there is Patient Fusion, a simple web-based portal that allows patients to see appointments, meds, allergies, immunizations and labs. It also provides some links to medical content on the web. It seems that the portal is very much a work in progress, but just like the EHR, its user interface is clean, simple and appealing. Unlike the EHR, which is Flash based and therefore unavailable for use on Apple mobile devices, the portal is accessible from an iPhone or an iPad. Practice Fusion did announce recently that a native version of its EHR for the iPhone is due to be released soon. 

Viability

Practice Fusion is privately owned and has been around since 2005, but started taking off in earnest around 2009. Its recent growth coincides with the HITECH act and the advent of Meaningful Use. Although it is possible that it will follow a trajectory similar to Southwest Airlines and blossom into a major EHR vendor, it is also possible that it would make a rather attractive acquisition target for one of the much bigger fish circling health care IT right now. Will it remain free to end users? There seems to be no current intent to charge customers for software usage, but Practice Fusion received over $36 million in venture capital, which usually comes with expectations of short term spectacular returns. Time will tell.

Bottom Line

Practice Fusion is currently certified for Meaningful use as a Complete EHR, which means that you don’t have to buy additional software in order to achieve Meaningful Use requirements. As is the case with all web-based EHRs, you will have to buy desktop (or mobile) hardware, internet services and networking hardware. You will still need to pay for a Practice Management system and billing, and unless you choose to utilize the sole Practice Fusion partner for these activities, you will need to budget staff time for double data entry. You will not need to pay for the EHR, its server and its maintenance. If you are interested in Meaningful Use incentives, and if you practice in a small group, and if the cost of EHR seems prohibitive (or a waste of good money), and if you have no use for bells and whistles above and beyond a paper chart, then by all means, go ahead and try it out. It’s free.

Occupy Health Care

Earlier this year, in the midst of the civil unrest in Egypt, Michael Millenson pondered about the passive attitude of those lacking health care insurance and their failure to organize and “take to the streets”. Well, unless you are living under a rock, or are really busy seeing patients, you know that we have quite a few people “taking to the streets” nowadays. They call themselves the 99% and they are set to Occupy Wall Street along with a bunch of other cities across the country. They have been called everything from “the rise of a popular movement” to “anti-American”. Are these Michael Millenson’s uninsured finally standing up for themselves? Judging from the stories they write on the placards covering their faces, which look eerily similar to what you see at busy urban intersections (e.g. “Lost home and job, will work for food”), lack of health insurance is often cited as a source of misery, but so are student loans, lost savings and inability to find work. Although this peaceful movement of folks camping out in parks and marching down streets has no coherent message, their grievances are casting a large net directed at the destructive influence of Wall Street, big corporations and consumerism in general. Michael Millenson should be satisfied, since health care is most definitely included in this all-encompassing indictment of an unjust society, and here is why.

But first a little detour into terminology. The word “care” originates from the Old English caru, cearu "sorrow, anxiety, grief," also "serious mental attention" for the noun, and carian, cearian "be anxious, grieve; to feel concern or interest" for the verb. When it comes to one’s health, with the exception of patients, their loved ones and increasingly fewer and fewer doctors, nobody in the medical complex experiences any feelings of anxiety, grief or even true interest or concern for the sick, although they may experience all of the above for the cash flow associated with treating sick people. The term health care is an anachronism from a bygone era and it needs to be changed. Health Services seems a much better fit with the prevailing consumer philosophy, which brings us to the next point.

Ever so gradually and insidiously, the term consumer is replacing the term patient in health services contexts, just like it replaced the term people in larger contexts. The etymology for the word consumer dates back to the early 15th century as "one who squanders or wastes", and in economic sense, "one who uses up goods or articles (opposite of producer) from 1745”. Interestingly enough those who presumably advocate for poor and vulnerable populations and even our own government are enthusiastically standing up for their constituencies of squanderers and wasters. Sometimes terminology describes existing realities and sometimes carefully chosen terminology shapes reality. We are witnessing the latter. The big corporations being targeted by those who Occupy Wall Street, have a long, and productive, history of manipulating the 99% into using up as many goods and articles as possible, and then some (i.e. debt), while extracting both profit and power from an increasingly impoverished society. Squandering and wasting is the secret sauce for a consumerist world order, and the medical complex is no different. According to Forbes, in the midst of a recession, CEO pay has increased in 2011 by 28% compared to 2010. The highest paid CEO in America, at $131 million per year (twice as much as the second CEO on the list), is running a health services company. Makes perfect sense. After all health services are quickly approaching 20% of a successful wasting and squandering economy. $131 million is peanuts by comparison.

But here the big corporations are encountering a big problem. The U.S. government, that is supporting a large portion of the waste and squander in the health services sector, is running out of money, and the squanderers themselves seem unwilling to waste their own money on health services. They much rather debt finance homes, cars and iPhones than, say, colonoscopies and designer drugs. The solution to this quandary is a brilliant one-two punch. First we use the bought and paid for government to educate consumers that in a world of finite resources, after skimming the $131 million type “compensations” from the top, only those who have their own resources (i.e. cash) should expect to continue wasting and squandering health services. Second, to compensate for lost revenue from government’s support of health services consumption, we employ two, time tested, strategies. We convert non-consumers to consumers by giving them free small things to lure them into buying more expensive items. For example, we give out free cholesterol screenings so we can create a recurring revenue stream from statins and hopefully more expensive interventions down the road. After all there is a huge untapped market of 50% of Americans who barely use any health services.  Then we increase the prices of everything from health insurance to direct services, by eliminate those obnoxious small businesses floundering in this space and fragmenting our ability to negotiate higher prices. The government is of course expected to help with the necessary laws and regulations, and so far, keep your fingers crossed, it’s going rather well. With a little bit of luck, smart consumers will soon realize that it is in their best interest to spend money they don’t have on the medical complex rather than the real estate market, which has gotten more than its share already, or the high tech gadget market which is booming, or the automotive market which is dead anyway (except for Audi who is selling cars for a crumbling infrastructure littered with trash). It’s all about reallocating extortion revenue and nobody is in a better position to do that than the medical complex. Brilliant indeed.

As the ancient prophet said “What has been will be again, what has been done will be done again; there is nothing new under the sun” [Ecclesiastes 1:9], all of the above has been tried before, in this case by the legendary Mullah Nasreddin, and we know how it ends:

One winter Nasreddin had very little money. His crops had been very bad that year, and he had to live very cheaply. He gave his donkey less food, and when after two days the donkey looked just the same, he said to himself, "The donkey was used to eating a lot. Now he is quickly getting used to eating less; and soon he will get used to living on almost nothing."
Each day Nasreddin gave the donkey a little less food, until it was hardly eating anything. Then one day, when the donkey was going to market with a loan[sic] of wood on its back, it suddenly died. "How unlucky I am," said Nasreddin. "Just when my donkey had got used to eating hardly anything, it came to the end of its days in this world."

To the 99% of us donkeys out there: Occupy Health Care Now!