This week The New York Times reported in Little Benefit Seen, So Far, in Electronic Patient Records that:
The nation is set to begin an ambitious program, backed by $19 billion in government incentives, to accelerate the adoption of computerized patient records in doctors’ offices and hospitals, replacing ink and paper. There is wide agreement that the conversion will bring better care and lower costs, saving the American health care system up to $100 billion a year by some estimates.
But a new study comparing 3,000 hospitals at various stages in the adoption of computerized health records has found little difference in the cost and quality of care.
“The way electronic medical records are used now has not yet had a real impact on the quality or cost of health care,” said Dr. Ashish K. Jha, an assistant professor at the Harvard School of Public Health, who led the research project.
The emphasis above is mine and as a technology strategist and evidence-based engineering proponent I was ecstatic to see that studies were being cited as opposed to just conjecture. The two things we’re most interested in from computerized records are improving quality of care and reducing costs. However, since we don’t track very good metrics and measures on either of the facets we’re looking to improve, it’s almost impossible to know how the simple act of creating electronic records will get us what we desire.
The EMR debate (if there is such a thing) reminds me of the CRM (customer relationship management) and SFA (sales force automation) debate in the non-healthcare sector of our economy. SFA is to other firms what EMRs are to clinical firms — CRMs help manage customer data longitudinally like EMRs help manage patient data. However, just like EMRs in medical firms haven’t proven to provide promised benefits, CRMs haven’t lived up to their promise either.
If you’re a CIO or executive and you’re trying to figure out what to do with EMRs in general take a look at the SFA space and see how well CRMs are doing across the industry. Lessons from the implementation of CRMs should help us figure out how to gain advantage from deployments of EMRs.
SoftwareAdvice.com recently posed the following questions to its readers in a survey format: “Are more doctors buying electronic medical records than before? Or, has the Stimulus bill only brought out the tire kickers?“. The results of the survey are available here; while the survey wasn’t scientific and it didn’t have enough participants to draw wide scale conclusions, the results do imply a general feeling of positive momentum towards the purchase and implementation of EMRs.
As an experienced healthcare IT professional I am very happy to see that people are looking towards EMRs and automation to improve healthcare staff productivity. However, I’d like to urge a bit of caution and be sure that buyers don’t jump into the market for the wrong reason. My rule about automation and insertion of software in any workflow process is simple: if you can’t repeat it, don’t bother automating it.
How to choose the right software and technology
For most potential users of EMRs, EHRs, and other “complex” workflow automation tools you should ease into the technology. What that means is that before you install any new technology, ensure that first and foremost it does no harm. All technology takes time to implement and get significant improvements; what’s important is that while you’re working towards improvement you don’t harm your business in the process. Technology should first and foremost not make a practice, department, or hospital worse off than it was before the technology was introduced. Then, it should start improving or “healing”.
Second, focus on interoperability and best of breed. Our desired tendency is to go for “all inclusive” or “complete solutions” but healthcare is too complex for any single vendor or package to do everything. By focusing on best of breed and interoperability you can grow at your pace and choose solutions that you really need versus those that the vendors think you need.
Third, Ask the right questions of your vendors and staff when they’re selecting any new technology. Don’t worry about features, functions, and technology. Worry more about your business (which is healthcare and patient happiness) by asking questions like this:
- Will my patient be more satisfied because I’m using the system?
- Will the outcome of care be improved because I’m using the system?
- Can I spend more time on my patient’s care versus documenting the encounter?
- How many more patients per day will I be able to see because of the system?
- Can I go home earlier because the system helps me finish my work faster?
- How many fewer lawsuits will be filed because I used the system?
Fourth, make sure the technology fits with your desired outcomes (not tasks). Almost any software will improve some aspects of your business — but, the question is will the software improve the aspects you care the most about? When asking technical questions, start with some of these:
- How can I easily transmit my patient’s medical records in a safe and secure manner without spending all day making copies?
- How many more lawsuits will I win because I used the system?
- How will the system be able to increase my patient population or help me market my services better?
- How much faster can I get paid for my services after I’m using the system?
- Can I get secure access to my data while I’m away from home or the office?
Fifth, be sure it can handle all the different kinds of data you have. Most vendors or technology providers focus you on what kinds of data they can manage. But, any reasonable office deals with all the following kinds of data and you need to make sure your selection can manage it:
- Structured data (fully coded ICD, CPT, etc)
- Semi-structured data (machine understandable but with keywords and such)
- Unstructured data (natural language)
- Images
- Faxes
- Audio
- Video
- Chat logs, e-mail logs
- probably many others
Most software systems handle structured data quite well. In fact, EMRs are an excellent way to capture structured data but in my experience structured data makes up only a small fraction of healthcare data. Semi-structured data and completely unstructured data along with faxes make up a big portion of data and medical images make up an even larger portion of the healthcare data pie. Video and email, chat, and other upcoming technologies will be taking up larger portions of database space as well.
When you’re choosing a technology, be sure to look at the kind of data you’re capturing regularly and ensure that the vendor you choose and the deployment model you pick are geared towards the data you create rather than the kind of data the vendor can store. Again, almost all vendors are great at structured data but there are very few that are good a non-structured data, faxes, images, and similar information. When looking at “cloud providers” (online software) make sure that the larger data you capture can be fit through your network pipes.
An EMR isn’t necessarily the first way to automate
While most people who are new to healthcare IT or looking to jump in quickly always point to EMRs as the most important application, there are actually many different healthcare IT applications that make up the “industry” as a whole. When you’re dealing with healthcare IT, EMRs might be a good entry point for some folks but it’s actually more likely that EMRs aren’t your first place to start your automation journey. These are some other techniques I’ve used to kick off automation before jumping into full-fledged EMRs:
- E-mail (beware of HIPAA, though) — internal office messaging and email is a great place to start. If you haven’t started your office automation journey here you should.
- E-Prescribing — e-prescribing is a great place to start your automation journey because it’s a fast way to realize how much slower the digital process is in capturing clinical data. If e-prescribing alone makes you slower in your job, EMRs will likely affect you even more. If you’re productive with e-prescribing then EMRs in general will make you more productive too.
- Office Online and Google Apps (scheduling, document sharing) — Google and Microsoft have some very nice online tools for managing contacts (your patients are contacts), scheduling (appointments), dirt simple document management, and getting everyone in the office “on the same page”. Before you jump into full-fledged EMRs see if these basic free tools can do the job for you.
- Clinical groupware — this is a new category of software that allows you to collaborate with colleagues on your most time-consuming or most-needy patients and leave the remainder of them as-is. By automating what’s taking the most of your time you don’t worry about the majority of patients who aren’t.
- Patient registry and CCR bulletin board — if you’re just looking for basic patient population management and not detailed office automation then patient registries and CCR databases are a great start. These don’t help with workflow but they do manage patient summaries.
- Document imaging — scanning and storing your paper documents is something that affects everyone; all scanners come with some basic imaging software that you can use for free. Once you’re good at scanning and paper digitization you can move to “medical grade” document managements that can improve productivity even more.
- Clinical content repository (CMS) — open source systems like Drupal and Joomla do a great job of content management and they can be adapted to do clinical content management.
- Electronic lab reporting — if labs are taking up most of your time, you can automate that pretty easily with web-based lab reporting systems.
- Electronic transcription — if clinical note taking is taking most of your time, you can automate that by using electronic transcribing.
- Speech recognition — another “point solution” to helping with capturing clinical notes; you can get a system up and running for under $250.
If you’re a physician or responsible for managing an office or an enterprise the government and vendors of technology solutions will be pressuring you to “jump on the bandwagon”. Tell them that Shahid said you shouldn’t don’t drink the Kool-Aid and that it’s ok to be afraid of bloated EMRs and ease into medical technology. 
•Technology should first and foremost not make a practice, department, or hospital worse off than it was before the technology was introduced. Then, it should start improving or “healing”.
Kevin Clifford and I were chatting about his experiences in taking a Michigan-area free clinic live on an open source EMR and I was very interested to share it with others. Kevin said he volunteered at the free clinic because he wanted to serve his community and said that there are many other such free clinics in need of IT improvements in Michigan and elsewhere. I asked him to write a quick summary of what he did and how it worked. What Kevin is doing is an excellent example for other IT firms looking to break into healthcare IT — use open source and other free tools to help your local community clinics and physician offices. Here’s what Kevin had to say about his experience:
I recently started volunteering at a free health clinic in Pontiac Michigan. The clinic has 30 doctors and dentists that volunteer their time seeing 500 to 600 uninsured patients per month. The clinic has an in-house pharmacy and three full time employees. I have an I/T background so my original intent was to help the clinic with any technical issues they may have such as setting up their website and network. Once I started working at the clinic I noticed they were having trouble keeping track of patient files and were making all appointments on paper. In addition they had to go through all their files monthly in order to track specific patient categories and follow-up on missing information.
I suggested to the clinic that they try OpenEMR, an open source EMR system. They liked the demo I showed them and I started the installation. I installed the OpenEMR appliance which runs on the VMware virtual server, the appliance allowed me to run the LAMP version of OpenEMR on a windows machine. I then configured the appliance so it would use a static IP address.
Once the program was up and running I changed the layouts and added fields for specific information that the clinic needed to collect. The most time consuming and labor intensive part of the install was in transferring all the patient records over to the program. Through the PHPMyAdmin part of the tool I was able to create the SQL queries that allowed the clinic to run the specialized reports that they needed. Our plan at the clinic is to continue exploring the capabilities of OpenEMR in order to improve the clinics efficiency even more.
The program has allowed the clinic to:
- Schedule patients and doctors electronically
- Manage patient encounters
- Save time by running reports on patient data
Due to the current economic environment the number of patients seen at the clinic has risen dramatically over the last year and there is currently a waiting list. There are a number of similar clinics located throughout the country that could improve efficiencies by installing an open source EMR system. I would like to expand the service on OpenEMR implementations to free medical clinics and am looking for thoughts and advice from the community.
If you have any suggestions or are interested in working with me on this endeavor please provide feedback here on Shahid’s site via comments if you want to speak publicly or if you prefer private communication you can contact me at kclifford@gmail.com.
One of the most popular questions that I am routinely asked about is how to get a job in the (now hot again) healthcare IT market. I was doing a little poking around on JuJu.com, a job search engine, and the nice folks there gave me some interesting statistics based on their usage patterns:
- IT positions make up approximately 3.5-7.0% of all healthcare jobs and this number is on the rise.
- Although the percentage of healthcare IT remains small relative to the healthcare field in general, there appears to be growing demand and consistent demand for this skill set as the field develops
- JuJu.com estimates that the number healthcare IT jobs has risen by about 10-15% since 2008, based on data, information, and postings on their site
The demand of course is organic and the need for better technology and information management in the healthcare market is fairly evident. If you’re not an expert in healthcare IT, how could enter the field? It’s actually a little easier than you might think but you’ll need to be creative. Here are some ideas.
- If you’ve got experience running or working in a medical office or you’re an experienced project manager you can apply for an implementation specialist or assistant at almost any healthcare IT firm like an EMR or EHR vendor, consulting firm, or systems integrator. The thing to keep in mind is that every customer that buys an EMR needs to have it installed and deployed and that’s done by implementation folks. There is a shortage of people that can take complex products like EHRs and EMRs live.
- If you have a little or a lot of general IT experience but no healthcare IT experience you can start by working in a technical support or training capacity. You would get the opportunity to learn new products and use your IT experience to provide customer service, support, and training talent.
- If you’re interested in the software side you can think of being a tester of software; vendors need good quality assurance and configuration management personnel and that’s a great place to begin your healthcare IT career.
- If you’re good at writing, consider joining the documentation team for creating training materials, videos, screencasts, or other related artifacts necessary to teach people how to use healthcare IT.
- If you’re a developer interested in writing software but you’re not experienced in healthcare, join one of the many open source projects that are out there building open source EMRs, EHRs, PHRs, and related tools. Open source is a great way to join a community of people willing to help you if you’re willing to give back to them, too.
- If you’re an integration specialist (you know EAI, EDI, EII, ETL, ESBs, or other integration techniques) start to learn HL7, CCR, and CCD and you can write your own ticket almost anywhere. The majority of healthcare problems in the IT arena are integration and deployment problems so if you know scripting and HL7 you’re good to go.
What if you can’t find a job because you don’t have enough experience and no one will hire you due to lack of experience? Well, then find one or more open source projects where you can help with documentation, training materials preparation, quality assurance, software code, design, configuration management, or a host of other tasks. By working on an open source project you will get the experience you need without having to be hired by someone. Then, you can use that on your resume to show that you’ve got capabilities because projective employers can actually download and see what you’ve done.
If you have other ideas for folks on how to break into the HIT job market, leave some comments here.
