BB&T Contributing Editor

BALTIMORE — The early-adopter phase of the electronic health record (EHR) market is history. We are now are awaiting the next phase — whether mainstream group medical practices will follow the trails blazed by the pioneers, or conclude that the journey to EHR technology is still too risky and overly expensive. Unfortunately, the Toward an Electronic Patient Record (TEPR) conference, held earlier this year, offered more of questions than answers on this issue.

It was a curious conference, for a number of reasons. It featured significant fireworks, as the organization named Certification Commission of Health Information Technology (CCHIT) held a “town meeting” with EHR vendors, many of them expressing shock concerning the costs of the certification that CCHIT is promoting. Another presentation was interesting in its frankness concerning the problems of the UK’s National Health Service (NHS) in deploying its version of a country-side health information technology (HIT) program. The conference also featured considerable rumination as to why EHR refuses to gain real traction in the U.S.

The CCHIT town meeting featured a heated exchange between EHR developers getting their first opportunity to voice their dissatisfaction with the CCHIT certification fee structure and CCHIT committee leadership, specifically its chair, Dr. Market Leavitt. Tempers flared as the developers said they felt pressed by the high fees for “voluntary” certifications (though not really voluntary, since CCHIT certification is being pushed by Medical Group Management Association and other MD proxy organizations as a marketing qualifier). And they said they already feel that high EHR costs are chilling adoption of this technology.

Costs – not among the obvious statements

Leavitt opened the meeting by stating the obvious; “The consensus is the U.S. must improve the quality and cost effectiveness of the healthcare system in our country. We have the highest cost per capita and rank the lowest in outcomes and quality than any other country.” He then restated CCHIT’s goals:

  • accelerating adoption of EHRs by reducing the risk of investing in information technology;
  • facilitating interoperability products within the emerging national information network;
  • enhancing the availability of adoption incentives and relieve regulatory barriers;
  • ensuring that health information products and networks always protect personnel health information.

Less obvious were the economic issues discussed. CCHIT currently is funded by a three-year $7.5 million government grant, but it then must become self-sustaining, with the meeting providing a glimpse of how this will happen. CCHIT certification fees have been set at $28,000 for the first year, and an additional $4,800 annual re-certification fee from the vendors. At the time of the TEPR meeting, 24 EHR vendors had already submitted their applications and fees, raising only about $675,000. Even if the 100 major EHR vendors (of 200-plus in the market) paid up, this would provide only $2.8 million the first year and about $480,000 per year thereafter, falling well below what the federal government felt necessary over three years.

Fees or taxes?

Many vendors at the meeting argued that the certification fee constituted a tax that would be passed along to physician-users and then to patients. And they said that the actual cost will be higher since many vendors will need sub-certifications, with the true total costs essentially impossible to estimate.

Leavitt’s response to vendor concerns about these high costs seemed to be: Get out your checkbooks. Though the session ran 30 minutes long, many issues were left unresolved. Vendors were obviously unsatisfied with the results and many have continued to vent their frustrations in other venues.

Nevertheless, checks are being written and systems are being certified.

Some blunt speaking

While opening sessions at many conferences are often less than newsworthy, this gathering was an exception. A representative of the American Medical Association (Chicago) rather bluntly told a packed auditorium of EHR developers to get on with it and fix the problems with their systems. This was followed by an equally direct presentation from Phil Sissons of Magic Consulting (London), who spent 18 months working as the supplier liaison manager for the Connecting for Health program of the UK’s NHS. Over 10 years, the national HIT program is to connect over 30,000 general practitioners in England to almost 300 hospitals and give patients access to their personal health and care information, transforming the way the NHS works. Sisson, however, emphasized mostly the key failures of this multi-billion pound e-initiative.

The program for 50 million patients is intended to provide an online booking system, a centralized medical records system, e-prescribing and fast computer network links among NHS organizations. One of the early areas that the NHS was hoping practitioners would use, called Choose and Book, is an online booking service that allows GPs and other primary care staff to make initial hospital or clinic outpatient appointments at a convenient time, date and place for patients. The thinking was that if a GP needed to refer a patient on to another physician/consultant, or even to choose a surgical date, the appointment could be made in the doctor’s office, essentially “on the spot.” But though Choose and Book has been available since the summer of 2004, few physicians are using it, Sissons said.

One success of this initiative he pointed to is the N3 Network System, a national network that will provide a combination of broadband connections and network services to link all NHS organizations in England, providing connection between existing network services without interruption. N3 Network also will enable the electronic transmission of visual data and images such as X-rays or scans and video-linked appointments with consultants, along with combined voice and data networks.

Under-bid and under budget

According to Sissons, one of the lessons learned from the UK initiative is that the 10-year project was, at 6.3 billion, significantly underbid. Additionally, UK general practitioners had wanted a choice of technology, but the IT overseers decided instead on rigid standardization, permeating the process with a “war zone” mentality, he said. The only medical disciplines that this did not affect were pathology and radiology, because those areas chose PACS. After a roll-out of 31 hospitals, all of these players were happy. However, other big players have already fallen away. And one of the original four IT vendors, Fujitsu Technology Solutions (Tokyo), withdrew and has been replaced by Cerner (Kansas City, Missouri).

He noted that influential academic leaders recently called for a formal audit of the NHS plan due to fears that it was behind schedule, over budget and not likely to work. In response, the NHS has denied any problem, noting that the project is under budget – which it is, since there has been such little adoption to date.

The lessons to be derived from the UK program, according to Sissons, are the recognition of past mistakes; a choice of products with a proven track record; system construction on a working platform; and articulation of a shared vision going forward. And Sissons’ audience was of course probably wondering if similar mistakes are being repeated in the U.S.

Mental health an outlier

One speaker on mental health automation was Dr. Ron Manderscheid, director of Mental Health and Substance Use Programs of the Constella Group (Durham, North Carolina), a provider of health intelligence and technology services to the public and non-profit sector. In his presentation, titled, “Behavioral Health runs the risk of being a Paper Island in an Electronic Sea,” Manderscheid confirmed what the rest of the healthcare industry well knows — that automation and HIT systems for mental health and substance abuse providers is lagging, especially in the adoption of EHRs.

Mental healthcare differs in several important ways: first, in its diversity of practitioners (psychiatrists, psychologists, counselors and social workers) and secondly, in the variety of patients served (from adolescent to geriatric populations). These providers also see patients in a variety of clinical settings, from small offices to hospital-based clinics. Thus, the challenge that mental health practices face is to identify common requirements and distinct differences in EHR software needs.

Like the rest of healthcare providers, the mental health field must adopt electronic billing solutions since 53% of its fees come from Medicare or Medicaid. But available EHRs are so vital sign- and medication-oriented that they don’t fit mental health practice needs well. Worse yet, the margin of profit for the behavioral health/substance abuse disciplines of care falls far below that of other healthcare specialties, making it difficult to take advantage of the benefits of new technologies.

One exhibitor addressing this, by offering behavioral/mental health and other healthcare automation solutions, was Estream (Pittsburgh), its software, services and expertise focused on human services organizations. Estream offers a system of workflow analysis, followed by redesign recommendations, which identifies ways for organizations in the behavioral sector to use the information they gather to improve workplace productivity. The software targets global efficiency issues as well as more specific concerns for improvements in intake, billing and clinical supervision, forms automation and a wide variety of recommendations.

‘Best of breed’ winners — and whiners

As usual, “winners” and “whiners” punctuated the always-controversial TEPR awards for Best of Breed EHR developers. Some of the controversy comes from a lack of understanding on the EHR developer’s part as to how the judging of their submissions actually works, and the process is rather thorough. It occurs in two phases, one that is completed before the TEPR meeting and results in the top three vendors in each category being invited to present at TEPR, and a second phase conducted at TEPR where a final judgment determines the ranking of the finalists determined before the meeting.

Each vendor pays a small submission fee, which covers the costs of judging and submits a set of answers to a very short questionnaire. They are also free to provide supplemental information about their products that goes beyond the answer to the specific questions asked, or which amplifies them. The packages submitted are then distributed to each judge and independently evaluated, resulting in a score falling somewhere on a 0-100 scale. And the vendor scores in a category can be very close. In one group less than 5 points separated the lowest and highest ranked vendors, two of which tied on the pre-conference phase of the judging process.

The conference presentations represent a clean slate for all of the vendors among the three finalists in each category, in that their pre-conference scores are dropped. Their success and final ranking depend solely on the quality and skill of their 15-minute presentation to the judges at TEPR, and they are then ranked against a small number of factors. While the vendors are told explicitly to demonstrate the diversity and features of their systems, it was clear that most had prepared their presentations ahead of time and that the content in some cases did not address the criteria that the judges were looking for.

This puts a premium on that 15-minute presentation, a difficult task since too short a time adequately differentiation from all the other systems. What results is that the quality of the presentation perhaps counts for more than it should. On any given day, any of the three finalists could win or place last, based on how their presentations. Those that win first place are elated and. the ones that don’t even make the second round feel some mistake has been made (often quite vocally expressed on the exhibit floor).

A New Category - PHR

Space doesn’t allow us to list all the winners, but this year’s awards featured a new category, that of the personal health record (PHRs), a specialized but growing niche that allows patients to enter their own medical information and make it available to whatever provider they select. PHR carried around by the patients themselves, would have been invaluable, for instance, during the Katrina disaster, in which paper and even electronic health records ended up under water and permanently destroyed.

Winners in this emerging category were: CapMed (Huntsville, Alabama), with its Personal Health Key product; and (in a tie) Medical Communications Systems (Woburn, Massachusetts) with its mMD.Net PHR, and Cerner (Kansas City, Missouri) with IQ Health First.

Specialty or non-specialty attendance?

While overall show attendance was probably up a bit this year, the population of attendees appeared not to include too many mainstream prospective adopters, such as business managers or doctors from mid-sized or small physician group practices. This poses a challenge for TEPR, as it does for Healthcare Information Management Systems (HIMSS; Chicago) — the other big association player and trade show sponsor — as to how to keep EHR developers coming when the prospects they are trying to sell to aren’t showing up in droves.

Indeed, most prospects are attending the trade shows hosted by their specialty organizations. Family docs are attending the meeting of the American Association of Family Practice (AAFP), practice managers are attending the conference of the Medical Group Management Association (Englewood, Colorado) and so on. EHR developers who have figured this out are swelling the ranks of these specialty shows, particularly if they have some installed base already in that specialty.

The disadvantage of focusing on the smaller, specialty-specific shows is that there are so many of them and thus runs up marketing costs. A four-day stint at TEPR can set an EHR developer back $12,000-$20,000, and a booth at HIMSS is even more expensive. Multiply this by 10-20 specialty groups and it quickly adds up, decreasing the willingness of smaller and mids-ized EHR developers to attend non-specialty aligned shows.

But overall, the growth of vendors exhibiting is a testimony to the expanding interest in EHR and the awareness among vendors that market identity is going to be key for tapping into this sector — if it ever ignites for the mainstream practice.

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