BBI Contributing Writer

FORT LAUDERDALE, Florida – Is the healthcare field really moving toward an electronic patient record? The Medical Record Institute's (MRI; Boston, Massachusetts) main objective for almost two decades has been to answer that question. And at its 20th annual Toward an Electronic Patient Record (TEPR) conference here, MRI declared that it was. But then the TEPR conference has been pushing for adoption of electronic medical records – EMRs, also called EHRs, for electronic health record – since their infancy and definitely has a bias to see them established. How far down the road the medical industry actually is toward the electronic record is not easy to determine.

One phrase that is often heard at TEPR and other conferences is, "If the banking industry can computerize and automate, the healthcare industry should be able to as well." This is a specious argument for an EMR system because there is no real comparison to be made between the two industries. The healthcare system is in need of a major overhaul and will have to (at some point) adopt an EMR/EHR, but the answer is not a matter of simply placing EMRs "just like the banking industry did." The following illustration of what would happen if the banking industry had to solve the same problems as the medical field demonstrates some of the discrepancies.

Assume that you need to get $10 from an ATM machine. After answering a series of questions about your past banking history on a screen, a message prints, "Your order has been processed. Please proceed with this referral slip to the ATM machine across town." You proceed to fight traffic for 30 minutes to get to the machine that contains your $10. Once there, you wait another 15 minutes for your order to be filled, only to find out that your $10 has been substituted with $10 Canadian because your bank does not want to pay the additional processing costs to give you U.S. $10. Needless to say, healthcare, for better or worse, is a much more complicated environment than the banking industry.

The 1999 Institute of Medicine (Washington) report, To Err Is Human, estimated that up to 98,000 deaths occur annually in U.S. hospitals due to medical errors. What if every banking error had the capability to end a life? Many of us would not be here today. Just as disturbing, those 98,000 deaths represent only U.S. hospital deaths; they do not include alternate care sites such as clinics, nursing homes, etc., where quality of care and education of staff usually is not as advanced as the inpatient hospital setting.

It is important to understand that the issue is not about physicians using computers because "everybody else is doing it." Each doctor has a different approach to medicine and offices have specific methods of billing, etc. that are unique to them, which does not allow for a one-system-fits-all approach. This will always be the case until the government provides the funds for thousands of third-party payers to update their antiquated computer systems so that they actually comply with new Health Insurance Portability and Accountability Act (HIPAA) billing formats.

Just the beginning, or close to the end?

The TEPR conference continues to be an enigma. Organizers describe the show as follows: "The team at MRI is ecstatic about the success of TEPR 2004, held May 17-21 in Fort Lauderdale, Florida. Attendee numbers reached an all-time high with just under 4,000 professionals, the exhibit floor held over 160 cutting-edge organizations, and the educational sessions provided over 400 highly educated presenters." While all of this is true, the vendors we canvassed said they felt TEPR was a good show from a business-to-business or "middleware" perspective, but many conceded that from an end-user standpoint there was disappointment. And of 3,700 pre-registered attendees, close to 800 were vendors.

For vendors, one of the most – if not the most – important reasons for attending a show is the ability to capture viable, qualified leads. Presentations and education sessions do not contribute to a company's bottom line – sales do. With the average cost of exhibiting at these shows ranging from tens of thousands of dollars on up, vendors will only continue to invest in a show's future if they sees a return on investment. Adding insult to injury, MRI organized a golf outing that ran parallel with the opening day of exhibits. Instead of delivering qualified leads to the exhibit floor, MRI took those leads out to the links. While only a few attended, this created the perception that TEPR wasn't valuing its vendors. Another much bigger problem for the exhibitors was that the content of presentations was compelling, drawing those in attendance away from the exhibit floor for a large part of the time the exhibits were open.

Many vendors and industry insiders polled at TEPR insist that the EMR/EHR market is starting to accelerate, although there still is much progress to be made. If hospitals and physicians' offices are indeed beginning to install systems, and adoption is being driven not only from technological advancement but from a privacy and payer standpoint as well, why can't this conference attract more vendors and attendees? One reason is that TEPR does not generate the press buzz that conferences like that of the Healthcare Information and Management Systems Society (HIMSS; Chicago, Illinois) and Medical Group Management Association (MGMA; Englewood, Colorado) continue to enjoy.

Market surveys & analysis: What do they say?

The TEPR conference was held in May and yet MRI did not have the results of its 6th annual Survey of Electronic Health Record Trends and Usage online at the time this article was written in June. Relying on the previous year's survey, "lack of adequate funding" was stated as the major barrier to implementing an EHR system, with a 64.2% response. According to the MGMA 2003 Cost Survey, revenue for multi-specialty group practices (prime candidates for electronic health records) increased by 5.67% in 2002 vs. figures for 2001. However, the cost of doing business increased by 7.47%. According to the same survey, 40% of respondents cite declining reimbursement as the most pressing issue they must deal with this year. The MGMA has more than 19,000 members that manage and lead 11,500 organizations in which about 237,000 physicians practice. Cost is definitely the major factor as to why adoption of such systems has been slow out of the gate. Privacy, security concerns, computer downtime and market place confusion over which products are best also contribute toward slow user adoption.

The statistics showing what is actually driving offices to institute a system are interesting as well. Beyond the obvious technological advances that have been made over the past couple of years (allowing for faster, more flexible computing), studies show there are other issues driving doctors toward the EMR. MRI's 5th annual survey showed that from an administration standpoint, facilitating workflow improvement (82.5%) and improving clinical documentation to support appropriate billing service levels (77.9%) were the leading reasons for moving to an EMR/EHR. From a clinician standpoint, the major draws were sharing patient record information among health practitioners and professionals (85.7%), improving quality of care (84.8%) and reducing medical errors (82.2%).

Are sales heating up?

Most vendors we spoke with at TEPR told us that sales were definitely going in the right direction. The annual HIMSS Leadership Survey revealed that 43% percent of respondents indicated they have either developed a plan to implement an electronic medical record system, or they have begun to install EMR/EHR hardware and software, but those who complete the HIMSS survey are mostly from the hospital or large physician practice space. A random sample of physician group practices done by Medical Strategic Planning (Lincroft, New Jersey) showed that a little over 22% of group practices have some type of EMR/EHR system installed. It also showed that of those practices currently without a system installed, 14.2% will have installed a system by the end of the year, and an additional 19.4% expressed that it is likely their practice would install an electronic record system in 2005. With more than 35,000 U.S. group practices, and over twice the current installed base planning on implementing a system over the next two years, it should be a busy time for vendors.

President George Bush, in his most recent State of the Union Address, said that "by computerizing health records, we can avoid dangerous medical mistakes, reduce costs and improve care. To protect the doctor-patient relationship, and keep good doctors doing good work, we must eliminate wasteful and frivolous medical lawsuits." Although talked about for years in medical circles, this was the first time EMRs were highlighted at such a high level of government and will surely raise national awareness. The White House expanded the idea by stating, "The president has set an ambitious goal of assuring that most Americans have electronic health records within the next 10 years. To achieve his 10-year goal, the president is taking the following steps to urge coordinated public and private sector efforts that will accelerate broader adoption of health information technologies." Whether this is pure goal or an attempt to win over more of the tech swing vote is yet to be determined, but interest in electronic records at the presidential level is sure to bring the issue more to the forefront (see following story).

Improved technology

Worth mentioning is that as technology continues to advance, some of the caveats that once plagued the electronic record community are disappearing. With processing speed and memory increases, charting systems that seemed to lurch ahead rather than blaze have met their match. Hardware technology seems to be finally catching up with the software luminaries. This is important to note, since the Medical Strategic Planning survey of group practices continues to show that there is some fear that the technology is unreliable and some respondents feel that a system would disrupt or slow down patient workflow.

Of the different hardware advances, probably the most important to note is the emergence of the tablet PC. Tablet PCs are the computer that most resembles a paper chart in a doctor's office or hospital setting. Laptops tend to be much heavier, especially for a nurse who has to carry it everywhere for an entire shift. The screen sizes on a tablet PC also are comparable to the screen size on many laptops, making them a better choice than PDAs for running a full-scale charting system as the processing ability of a PDA currently dulls in comparison to a tablet PC. Giving credence to this is another set of data found in MRI's 5th annual survey. The question posed was, "If you are using mobile/wireless devices for healthcare applications, which ones are they?" The answers were that 46.9% of respondents were using laptops, while 36.5% were using PDAs and 20.4% were already using tablet PCs. This is a significant number considering laptop computers and PDA devices have been around much longer. We looked at tablet PCs in depth at this year's conference and believe that Motion Computing's (Austin, Texas) M1400 is the best available unit.

Daryl Stanbery from Hitachi (San Jose, California) gave a presentation comparing the power consumption of a standard PC to that found in a Thin Client Tablet PC and found a saving of close to $140 in operating costs on a three-year basis. When offices have 50 to 100 devices, those numbers can add up, even if the cost-saving ends up being less than those presented. Hitachi was at TEPR demonstrating its VisionPlate mobile computing technologies.

Of the various companies demonstrating Tablet PCs and mobile computing platforms, Electrovaya (Ontario, California) also stood out, offering a tablet/ laptop CPU with the longest operating time, up to 16 hours (typically five to nine hours in its Scribbler Tablet PC) running an Intel Centrino processor in a 3.1-pound package. Electrovaya was the only manufacturer able to achieve a full nursing shift of operating time without the need of an auxiliary battery pack or battery swap. To achieve this, Electrovaya uses the latest Lithium-ion, super-polymer battery technologies. Both Toshiba (New York) and Fujitsu (Tokyo) also were able to reach up to eight hours' battery life, but with an extended battery. The trade-off with the extra batteries is additional weight, which again will limit the appeal to anyone who has to carry one around for eight hours. Motion Computing's M1400 model allowed a power-on hot battery swap, a convenient feature.

Panasonic (Secaucus, New Jersey) was showing its Toughbook line of "ruggedized" laptops and tablet PCs, ruggedized to survive the occasional drop that can occur in hectic medical environments. Panasonic representatives referenced literature that pointed to notebook PC damage rates climbing 22.5% over the last three years. Although they point to the Toughbook as being a significant return on investment, nothing is free. The ruggedized version of these computers was roughly $1,000 over other laptops or tablets with similar specs. However, in an industry where "up time" is vital, these machines can take a licking and continue ticking. The other downside of these beefed-up products was the battery operating time averaging four to five hours, not competitive to the Electrovaya products. It is worth noting that when informed of the Panasonic Toughbook's ability to take a hit, an Electrovaya official proceeded to drop his tablet PC to the ground without it suffering any apparent damage.

But the most interesting tablet vendor at TEPR was Motion Computing, offering a combination of features unmatched by the units discussed above. This is one vendor that pays attention to the needs of the medical information systems market and as a result partners with several EMR/EHR software companies. At TEPR, Mountain Medical Technologies (Incline Village, Nevada) was one of Motion's partners exhibiting its EMR. Mountain Medical has developed an application service provider (ASP)-based EMR and priced very aggressively for smaller practices.

Are patients ready?

One of the final pieces to the EMR/EHR puzzle is patients' willingness to trade away the human touch for a computerized one. Many doctors cite computers as being too impersonal for their practice; however, we are living in a technological age where computers are used in almost every facet of life. From the banking industry to grocery stores to home computers (more than half of U.S. households are connected to the Internet), computers are a part of daily life.

It is important to help patients understand that computers are not replacing the doctors but rather aiding them in diagnosing illnesses as well as capturing patient history and allowing them to move their personal records with them on a simple CD or USB device.

The public is not demanding that these systems be put in place, but would the tune be different if they truly appreciated that 98,000 people died yearly from adverse drug events? That is the equivalent of more than three dozen 9/11 attacks per year! Would they like their pharmacist to be able to read their doctors' handwriting? This is not yet a consumer-driven market; but with the attention being paid at the highest government levels, and with many group practices and larger hospital systems expected to have something installed by 2006, consumers will be involved soon.

Attitudes are changing from a vendor standpoint as a whole as well. During one end-user presentation at TEPR, the speaker boldly exclaimed, "75% of our doctors are using the system; we consider this a complete success."

There are many vendors now arguing for phased adoption of these systems, also known as "modular" installation. The approach is not to overwhelm doctors with a product, but instead to phase them into a total solution. This approach lets them do one piece first, such as prescription ordering or lab results, and then as their confidence in the system builds, more pieces or modules are added. Vendors also recognize that it is very difficult to take different practices or hospitals and stuff them into a one-size-fits-all box. Vendors are realizing that they have to cater to a specific office's workflow or way of performing medicine.

From the exhibit floor

Dictaphone (Stratford, Connecticut) showcased its new EMR software that integrates its natural language processing technology to offer a physician-friendly solution that converts free-form dictation into structured data suitable for EMR data population. PMSI (Seattle, Washington) was showing new software versions with new diagnostic-specific protocols, context message generation and Dragon-based voice-recognition options. The Motion Tablet allows this dictation to be made without a special headset in areas with reasonable ambient noise.

One solution to medical record transfer is to have the patient carry their medical record with them or to have it stored on a web site that can be accessed with the patient's permission by any hospital or provider in an emergency situation. Nextgen (Horsham, Pennsylvania) was talking about its partnership with BioImaging's CapMed personal health record USB keys. These are the repository for patients to carry their vital health record information with them. This idea, used widely in some European countries, seems to be finally gaining traction in the U.S. market.

Siemens Medical Solutions (Malvern, Pennsylvania) was rolling out its work-in-progress, ReachMyDoctor software, an integrated practice management and EHR offering that features secure messaging between physicians using portable or PDA type devices. The company said it was looking for a few sites willing to beta test this product.

Amicore (Andover, Massachusetts) was launching new specialty-focused EHRs for cardiology, urology, family practice and internal medicine specialties. These reportedly will be sold through Pfizer's (New York) 12,000 drug sales reps and through Amicore's 12 direct sales reps. Amicore has a better chance of succeeding due to the number of people selling it. Distribution channels are becoming more important as the market continues to consolidate.

One company that continued to impress us was Dr. Notes (Boca Raton, Florida), formed by Dr. Angel Garcia in 1987. The company has experienced a sharp revenue growth over the last 30 months. Dr. Notes is developing an increasing number of links to other systems and claims to have modules available for 38 different practice specialties.

Market consolidator Companion Technologies (Midvale, Utah) was showing its recently acquired Medawest practice management system, now re-branded Companion PM, and its recently acquired Medicware EHR, now re-branded Companion EHR. It is focusing on the community health center, family practice and ambulatory care applications.

The need for work-flow management was a theme of the presentations at TEPR, with several speakers and a track on this topic. Isprit Systems in Medicine (Indianapolis, Indiana) was showing its new EHR system, one of few vendors that has designed its system from the ground up based on a disease management paradigm with user controlled, work flow management. Isprit currently supports 12 chronic disease specialties, including diabetes and hypertension, and is planning to add additional diseases in the future. The company, which launched earlier this year, claims 30 customers, but how many of these are installed and live is unknown. JMJ Technologies (Atlanta, Georgia) is another such company that attended TEPR and the HIMSS conference earlier this year.

InteGreat (Scottsdale, Arizona) was showing a new portal that provided it access to partner systems provided by Kryptic (Beaverton, Oregon) and PrimeTime Medical Software (Columbia, South Carolina). This new company has less than 20 installs and is focusing on physician group practices of 50 or more physicians. InteGreat announced that it will be adding some disease management features to its system during the later half of 2004.

Solventus (Pompano Beach, Florida) was another web-based EHR firm that focuses on smaller practices. The company lacks some features of other systems but intends to be the lowest-cost provider to the PGP EHR space. Yet a third web-based EHR and practice management system vendor exhibiting at TEPR was SynaMed (Kew Gardens, New York). This system is suitable for practices of all sizes,according to Robert Yacavone, MD, who spoke with us. The system is fairly pricey, so the payback would be fastest in larger practices that do a lot of transcription, which can be circumvented by adoption of this electronic approach.

Most EHRs work well in creating new electronic records, but installation requires dealing with the issue of existing paper records. SRS Software (Montvale, New Jersey) is one of several vendors that provide a paper record scanning solution that indexes the old chart by patient ID only. While this solution does not allow data in the charts to be indexed, it does provide rapid access to the chart itself. It could be a viable first step of a two-step process, which includes capturing the chart optically and then mining it manually to create a basic patient profile and encounter history summary, prior to discarding the existing paper records.

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