BBI Contributing Editor

SALT LAKE CITY The 2005 Toward an Electronic Patient Record (TEPR) meeting held here in mid-May was in many ways a more exciting and more significant conference than the Healthcare Information and Management Systems Society (HIMSS; Chicago) conference, the premier gathering for information technology in medicine. While attendance was much lower (slightly fewer than 4,000) compared to HIMSS (nearly 23,000), the show attracted many physician group buyers and 182 exhibitors. The educational sessions also were of a high quality and with fewer tracks, easier for attendees to navigate. There was a good balance between exhibit time and education session time. TEPR seems to have found its niche.

TEPR, conducted by the Medical Records Institute (Boston), was the venue used by new companies to introduce themselves to the market and for many existing vendors to announce product enhancements. In the new-hardware department, Motion Computing (Austin, Texas) unveiled its new Motion LE 1600 tablet PC. This worthy successor to the popular M 1400 keeps the same screen size but adds performance. Processor speed has been increased, as has the speed of the front-side bus, resulting in a significant overall performance boost. Options to double the amount of memory and disk space also were added and a third noise-canceling microphone was added. This means that whether the tablet is used in "portrait" or "landscape" orientation, there always are two microphones active for voice recognition of dictation no external microphone required. The tablet's user dashboard controls make adjusting the sensitivity of the noise-canceling feature a snap.

Carried over but relocated is the computer's biometric ID, used by the Windows OS to identify the user and by the application to authenticate user login. The package sustains the wide viewing angle, features the same "in sunlight" contrast adjustment and weighs in at two to three pounds, depending upon whether the optional battery is attached. With the standard battery, operating time is four hours, the same as the M 1400. But with the optional battery snapped on the back, the operating time doubles to more than eight hours. The docking station has been enhanced with posts that the tablet slides into, simultaneously mating with the system connector to create connectivity with docking station peripherals. A new, Bluetooth wireless keyboard rounds out the enhancements on this powerful new tablet.

Making docking stations and mounting accessories for all the laptops we saw was Ergotron (Fort Collins, Colorado). Given the array of (as yet) non-standardized laptops and tablets, the company has its work cut out for it, but does a nice job nonetheless.

Panasonic (Secaucus, New Jersey) was showing its Touchbook series, but we didn't see any new models. These are also well done, but substantially more expensive than Motion Computing's, particularly in the ruggedized version that can sustain multiple drops from three feet without damage. If a rugged design is an absolute necessity, Panasonic is the choice, but the price is almost double that of any consumer tablet from its competitors. This was developed for military and other use where abuse is the rule, rather than the exception.

Fujitsu (Sunnyvale, California) was represented by some of its application partners, and we did not see any new units from this competitor. One innovative new electronic health record (EHR) vendor, WiFiMed (Maynard, Massachusetts), has built its product on top of the Fujitsu tablet PC, although the software itself also could run easily on Motion Computing's M-series portables. Hewlett Packard (Littleton, Massachusetts) also was showing its tablets, as was Electrovaya (Mississauga, Ontario), a company known for its unique battery technology that provides 10 or more hours of operating time. Techvisions (Temecula, California) is a medical computer platform newcomer that, like Panasonic, was offering a hand-held tablet, ruggedized PC for medical applications. The smaller screen, however, only supported resolutions up to 800 x 600, which would be inadequate for hosting many EHR applications, and the product also offered only four hours of operating time until batteries had to be recharged. The price was also a bit steep compared to competitors. Of the units we saw, this was the least customized for the specific security and other needs of the medical application space.

For providers who already have computer hardware without biometric scanners built in, Ultrascan (Amherst, New York) was showing its line of add-on biometric ID products, which includes an entire infrastructure of ID products, ranging from devices for individual computers up to and including an entire, enterprise-wide infrastructure that includes a central (enterprise-wide) master patient index (EMPI) capability.

Another interesting new company was MedKey (San Diego), which reported a partnership with SanDisk, a maker of USB flash memory storage devices, at HIMSS. Three months later it was showing a SanDisk USB device with two application programs and a blank CCR (continuity of care record) database embedded. Plug this small device into any PC (tablet or laptop) running Windows and the user application loads, allowing the person to enter their medical information, which is then stored back onto the USB device in a format that meets the current draft CCR ASTM format. The person then carries it with them to any provider, where the provider plugs it into their computer. If the provider has an electronic health record that is CCR-enabled, the data will be downloaded and will populate the EHR database. If the computer does not have an EHR or is one that is not CCR-enabled, the application program for the physician loads off the USB and then accepts the patient data from the USB, populating it into a simple file the practice can access.

Many EHRs are becoming CCR-compatible as the CCR moves from a draft standard to an adopted, international standard, something scheduled to happen this month (see below). So MedKey is on the verge of becoming the universal CCR broker, much as Adobe has with its popular PDF document format. As this occurs, it will nullify other proprietary formats for the PHS (personal health record) that have been introduced by several other companies, essentially merging the CCR and PHS formats into one an achievement that will be good for everyone, in our opinion.

Progress toward adoption of the CCR draft as a new ASTM International (West Conshohocken, Pennsylvania) standard also was reported at TEPR. There was feedback to the second ballot on the CCR, and a meeting conducted in late April to address and work out comments. A subsequent two-day meeting was scheduled for June in Washington to finish dealing with comments, after which the draft standard will be adopted as a new ASTM standard. This seems quite certain as the ASTM is taking the unusual step of actually publishing the current Draft Standard to vendors before it has been formally adopted, something it seldom does but something there was a lot of vendor pressure to do. Formal adoption and publication of the final standard is expected by this month. The presentation of the CCR status was made by Daniel Smith, director of technical committee operations of the ASTM. Copies of the current draft standard are being sold on the ASTM web site until the final version is available.

On the services front, Waiting Room Solutions (Goshen, New York) was offering instant web sites for physicians. Doctors who are ready to create an electronic presence on the web can be up and running with a basic site in less than 48 hours, and with a more complex site in a couple of weeks. The company has eight developers and can augment its basic site with computer practice management (CPM) functionality such as patient appointment requests, calendar and scheduling and other services, making Waiting Room a bridge strategy for practices looking to phase out the front desk functions of their existing CPM and adopt a web-based solution from a new supplier.

The software front was where the most action was at TEPR. In terms of back-end, structured databases, SnoMed CT, part of the American College of Pathologists (Northfield, Illinois), was showing its standard product. Only thing new was a developer's tool that allows developers integrating SnoMed CT to slice down the enormous structure and slice off pieces not needed for a particular clinical context. This allows EHRs intended for specific practices specialties to shed much of the non-relevant structure of SnoMed CT that were developed and intended for other clinical settings and specialties. This ontology is now free, but competes with Medicomp's (Chantilly, Virginia) Medcin ontology and back-end knowledgebase. While Medcin was not exhibiting at TEPR, the HER vendors that have integrated Medcin were present and made their presence known during the vendor documentations shoot-outs.

Of the Medcin-enabled EHRs, the one that seems to have done the most efficient implementation was Medcomsoft (Toronto). The key with EHR vendors using either SnoMed or Medcin is to narrow the "pick lists" down to the point that the physician is not slowed down during the physical exam. Indeed, this problem is the basis for the two different approaches taken to EHR implementation by vendors, that of front-end, structured (pick list or template-driven) approaches vs. the EHR vendors promoting dictation, free-form or other non-structured EHR approaches. Both EHR vendor camps were in attendance at TEPR, giving attending physicians and practice managers a good chance to compare these two approaches during the documentation shoot-out.

HIPAA, workflow compliance

The two hottest themes at TEPR were HIPAA compliance and workflow management. Indeed, the workflow management track was the only track that spanned two days, and was very well attended, prompting its relocation from the normal meeting rooms into a small ballroom at the conference center. This indicates how important workflow management has become and how clearly it is associated with enhancing practice efficiency when implementing EHRs. Dr. Chuck Webster, who is associated with JMJ Technologies (Atlanta), led the track, which had dozens of speakers addressing various aspects of how to enhance workflow. The challenge for many of the larger, better-known vendors is to integrate after the fact, a workflow management "engine" into their existing EHR products. This is not an easy thing to do after the EHR has already been designed and implemented. Many of the newer, smaller vendors that have based their EHR systems on products like Microsoft's (Redmond, Washington) .net platform, in object-oriented languages, either have already integrated workflow management engines or will have a much easier time of retrofitting them than their larger competitors who are still using archaic, legacy foundations and databases.

JMJ Technologies was showing its Encounter Pro EHR, which has an embedded workflow engine, but the slickest implementation of an EHR we saw from the perspective of integrated work flow management was a new EHR from a new company, WiFiMed. Its initial entry into the EHR market has been in the mental health EHR space, serving psychiatrists and psychologists. However, the company is quickly developing workflow management-enabled packages for other specialties as well. While, like any new EHR product just being introduced as version 1, there were some limitations of the WiFiMed product, it didn't strike us that it would be long before they were addressed and resolved. With proper marketing, this company could be positioned to emerge quickly in the EHR market.

WiFiMed was not the only new EHR vendor at TEPR. Bond Technologies (Tampa, Florida) was one of the more complete newcomers to TEPR 2005. We had seen an early version at last year's meeting, but now the company's Bond Clinician product is released and much more solid. With the ability to run on a variety of platforms, including the increasingly popular tablets, it is very flexible. It is integrated with a computer practice management capability, so it provides a nice migration path for Medical Manager or other legacy CPM products. The Bond applications are .net, specific to the Microsoft platforms and priced to not break the budget of smaller group practices. This is just one of several newer EHR vendors who seem to be migrating to the Microsoft .net platform.

PMSI (Seattle) was showing its waiting room kiosk application and other EHR enhancements. PMSI is the creator of the popular Practice Partner, CPM and EHR software. This is a very solid template-driven product, and PMSI has been one company to offer an excellent computerized practice order entry (CPOE) product. PMSI is among a handful of profitable medical IT vendors, with a sizeable base of more than 1,300 installed sites. It specializes in mid-to-larger, multi-office, multi-specialty practices.

NextGen (Horsham, Pennsylvania) was exhibiting but seemed to have changed its marketing approach since its alliance with Siemens Medical Solutions (Malvern, Pennsylvania), becoming a little less "colorful." Indeed, NextGen finds itself in an interesting predicament, somewhat a victim of its own recent success. The company was rumored to be for sale late last year, but after a recent flurry of new EHR orders, its valuation went up dramatically, pushing its price out of the range that most companies are willing to pay. If it is now acquired, it will probably be by one of the larger EHR competitors. Since Cerner (Kansas City, Missouri) already has acquired VitalWorks (Ridgefvield, Connecticut), it is probably not in the market for any EHR vendor. GE Healthcare (Waukesha, Wisconsin) already has acquired Millbrook (Carrollton, Texas), and probably is not interested although with GE, that is a dangerous statement to make. That leaves Siemens or perhaps McKesson (San Francisco). NextGen is a company that smaller competitors may want to watch, to learn what to do when a company suddenly makes a jump in market share.

Allscripts (Libertyville, Illinois) was showing its traditional EHR as well as its newer ImpactMD (formerly AIC) scanning approach to EHR. Until acquired, ImpactMD had been the only other major competitor of SRS Software (Montvale, New Jersey) and its EasyEHR (scanning-based) approach to electronic health records. Several physicians we talked with on the TEPR exhibit floor, who departed the Allscripts booth and were headed to competitors' booths, indicated concerns about the legacy database that is embedded in the older Allscripts EHR products.

SRS Software was one bridge approach to full EHR implementation that was among the fastest, easiest-to-implement and efficient-to-use EHRs we have seen. The system works by scanning in the existing paper charts, grouping and organizing pages from the paper records into indexed images and storing the entire paper record in PDF (image) format. This is an excellent solution for transforming existing paper charts into an electronic, readily retrieved EHR format. It lacks structured query capabilities, but almost no approach to dealing with existing paper charts (that is quick and inexpensive to implement) results in a structured EHR format.

SRS also offers a set of nursing tools structured to capture some elements of the patient's chart, but allows physicians to continue to dictate their findings, which are then transcribed and scanned into the SRS electronic health record. While this later text remains unstructured a fact that its competitors attempt to exploit the success of the SRS approach is undeniable. It has more than 200 live sites, all of which are happy and none of which have been de-installed. That is something that is notable, given national healthcare IT czar Dr. David Brailer's comments that about half of EHRs that are installed fail, and compares well to larger competitors selling template-based, pick list-enabled, structured EHRs, which have experienced notable de-installs.

While not as well known as NextGen, SRS has nearly two-thirds as many sites live and has been noted as one of the seven upcoming companies by Healthcare Informatics magazine. The company also has alliances with Allscripts and various other EHR companies that have structured EHR products, which allow them to import records created by the SRS product. It also has a deal involving GE Healthcare's Centricity (former Logician) EHR and with others, making the company the Switzerland (think neutral) of EHR products. This offers SRS clients who wish to migrate to fully structured EHR products later on, able to select from a number of popular templates or pick list-based EHRs that other competitors offer. The list of such vendors with whom SRS is compatible is growing rapidly. Watch for an alliance yet this year between SRS and Dictaphone (Stratford, Connecticut).

Dictaphone is the granddaddy of dictation-driven systems and is offering a true bridge between the unstructured, dictated medical record and a fully structured (SnoMed CT-compatible) structured EHR. How it performs this magic is quite interesting. Dictaphone was the holder of all of the voice recognition technology from Lernout & Hauspie, which went bankrupt and whose senior manager went to jail. That included Dragon Systems (Newton, Massachusetts). Subsequently Dictaphone sold Dragon to ScanSoft (Peabody, Massachusetts), maker of the popular consumer Omnipage OCR and OmniForm, PDF-based document storage solutions. Dragon brought voice recognition (VR) technology to ScanSoft. But the deal left Dictaphone with a perpetual license to new ScanSoft enhancements and the ability to modify/append source code to new Dragon versions. Dictaphone takes Dragon's Medical (version 8) software and throws out its vocabulary of words, substituting its own, less-extensive, more practice-specific vocabulary, which immediately improves accuracy of recognition of dictation in limited medical domain spaces, such as radiology or pathology. It then adds the magical, rule-based "natural language processing" (NLP) backend that takes the free-form unstructured, dictated medical record and transforms it into a fully, SnoMed CT-compatible medical record, which the system saves.

If this NLP technology works well, Dictaphone stands to clean up in the EHR space because freeform, unstructured dictation is clearly a method that many doctors prefer to use. It is fast and highly efficient on the front end, but can now be transformed into a fully structured record required on the back end to support queries, standardized quality reports and all the other advantages of a template-driven, structured EHR (which is not nearly as efficient on the front end for doctors to use). Dictaphone therefore offers the best of both worlds, if it actually works.

Rounding out the transcription approaches was Kryptiq (Hillsboro, Oregon). Kryptiq, like SRS, is working to integrate itself various other vendors. It started with GE Healthcare's Millbrook product (now Centricity). They also are HL7 (version 2)-compliant, support the CCR and work with IHE vendors. The company does its own interfacing, rather than depending upon a middleware interface engine according to a company representative whom we talked with at TEPR.

Web-MD Practice Services (Tampa, Florida) was showing its Medical Manager (Unix-based) EHR and its newer Windows-based, web-enabled EHR, but not explaining (to us at least) what the customer migration path from one to the other was. There was a new senior management team on hand at TEPR compared to a year ago and it seemed that the relationship between Web-MD and its current Medical Manager customer base was not completely settled. Several of its competitors are targeting and raiding its extensive Medical Manager installed base, converting them to integrated EHR/CPM applications that replace Medical Manager and add a viable EHR product that runs on a single code set and database.

There is no doubt that the EHR market is heating up, that buyers are moving toward more integrated EHR with CPM approaches, that the smaller vendors with the newer .net, web-enabled solutions are offering the most advanced features and that the larger vendors are struggling to lower their cost structure. The "sweet spot" for new EHR rollouts is group practices three to five doctors in size, in the $7,000 to $9,000 range per license. As the practice size increases, the price moves down to around $5,000 to $6,000 per license. On top of this is layered an ongoing maintenance agreement that ranges typically in the 12% to 18% range of the initial software costs per year.

While a few vendors are offering combined hardware and software systems, the majority don't sell the hardware, but only run their software on customers' hardware or focus on an application service provider model to minimize hardware platform issues at the office level, actually running their applications on their Internet servers. Prospective buyers who attended TEPR may have been exposed to too much information, as there were 141 vendors exhibiting. But they certainly were exposed to a wealth of different vendors and approaches.

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