BBI Contributing Editor

ORLANDO, Florida The annual Health Information and Management Systems Society (HIMSS; Chicago, Illinois) meeting is a place to track the ongoing state of conversion of physician group practices (PGP) from paper to the electronic health record (EHR). Many PGPs are fearful of taking the EHR leap, for a variety of reasons ranging from training time to the cost involved (see sidebar, page 134). Their concerns are blocking more widespread adoption of the EHR and, unfortunately, neither industry pundits nor EHR vendors are paying enough attention to them. Indeed, many EHR vendors think it is good enough if they sell their software alone, leaving the task of selecting the hardware and managing the rollout implementation to the end user, many of whom already believe they are not up to that task.

There are exceptions, of course companies such as Epic (Madison, Wisconsin) and a few others that have a commitment to their customers. But the cost of their EHR products is high enough that only the largest PGPs (those with 150 physicians or more) are big enough to have the needed healthcare information technology personnel on staff or to afford such comprehensive solutions. Many vendors that seek to deploy the EHR to smaller practices those that make up (numerically) the vast majority of the market do not offer a complete solution, usually settling for a "software only" product offering. Finally, almost all practices in the five- to 25-doctor range are concerned about how to finance an EHR. As a result, though many PGPs understand and agree with the ultimate benefits of the EHR, they are reluctant to jump in and make the enormous changes they perceive an EHR represents. These folks are looking for a less radical, step-wise approach that moves them toward an electronic health record, but not all the way to one in a single step.

Increasingly, physician group practices are seeking some form of transcription as a bridge across this EHR adoption chasm. Once a dictated encounter is transcribed, it can presumably be captured electronically as at least a "free-form" document that can be indexed and made searchable if only for key words or phrases. This is a step, albeit a small one, toward an EHR in the minds of many practices one that requires little modification and minimal disruption to how PGPs currently practice medicine. As a result, a number of transcription companies including market leader MedQuist (Marlton, New Jersey), now owned by Royal Philips, Lanier (Atlanta, Georgia), Acusis (Pittsburgh, Pennsylvania), Speris (Franklin, Tennessee) and others have seen their businesses and product adoption grow over the last two years in particular. Companies such as Acusis use the Internet to deliver voice to India and transcribe it there, delivering back electronic documents again via the Internet. The company has been partnering for the last several months with MedAptus (Boston, Massachusetts), whose Charges-in-Hand pocket PC-based software becomes a portable, wireless dictation input to the Acusis transcription global network, which then provided completely transcribed records back within 24 hours.

Other competitors deliver to sites either inside the U.S. or closer to the U.S. In all cases, security of the information in transit and by the transcription company is a serious consideration. Transcription has basically two components. One is the technology infrastructure that captures the dictation and delivers it to the point of transcription and the second is the actual transcription itself. Some companies such as MedQuist offer both parts of the solution into one service. Others offer just the infrastructure, allowing the PGP to select among other alternatives for the second, transcription part of the solution.

Speech recognition an alternative

One alternative to automating the manual transcription process, if accuracy is acceptable, is speech recognition. Even when speech recognition is not of sufficient accuracy to totally automate transcription, it may still have sufficient accuracy to transcribe most of the dictated record and thereby minimize the time required for totally manual transcription, thus saving money as the transcriptionist simply corrects the minimal mistakes that the speech recognition system (SRT) actually makes. This may explain why speech recognition ranks before adoption of the EHR in the latest HIMSS survey. Many transcription companies are adding SRT as a means of controlling or lowering total transcription costs so as to hold onto their customers. Many PGPs complain that transcription costs are rising, and they are now looking to separate the transcription delivery technology (that transports voice to the point of transcription) from the actual transcription services themselves. Larger suppliers such as MedQuist combine both services into one product. Some smaller suppliers are now focusing in on just the delivery component. This allows large, multi-practice integrated health networks or integrated delivery networks to collect all voice at one point and then choose who does the transcription, either keeping it in-house or farming it out to a transcription company (that may or may not be the voice delivery company).

Transcribed dictation provides electronic format but not well-indexed and useful knowledge repositories. Indeed, transforming one into the other is a major undertaking, since transcribed data is essentially freeform data, lacking the rigorous structure to allow easy cataloging against either simple billing codes (ICD or CPT) or against much more complex clinical language repositories such as those supplied by Medicomp's (Chantilly, Virginia) Medcin, SnoMed (Northfield, Illinois) and Apelon (Ridgefield, Connecticut). Indeed, Apelon announced in February the selection of its Distributed Terminology System for the Center for Disease Control and Prevention's (CDC; Atlanta, Georgia) Enterprise Vocabulary System project. Other current CDC information system development initiatives include the National Electronic Disease Surveillance System and some components of the Public Health Information Network.

Dictaphone (Stratford, Connecticut), a company that has been around for more than 100 years, has moved far beyond transcription to now offering Enterprise Express, a family of integrated digital dictation, transcription and report management solutions that allows healthcare organizations to manage dictated voice input, report-transcription and distribution across multiple departments and facilities, while centrally managing system supervisory functions and workflow. This system, shown at HIMSS, consists of a dictation and transcription software suite with workflow management tools as well as the Enterprise Express TextSystem, a transcription and document management system. This all happened following its disastrous acquisition by Lernout & Hauspie (L&H) in 2000. L&H had numerous accounting irregularities, but Dictaphone emerged from Chapter 11 bankruptcy in 2002 as a privately held organization and has continued to offer innovative products since that time. For example, Dictaphone claims an accuracy rate of 97% to 98% for its ExSpeech product, which uses a subset of SnoMed, that "reads" text from dictated narrative reports, dealing with issues of negation and language ambiguities, and then identifies, extracts and structures selected pieces of information.

Provox (Roanoke, Virginia) also was showing a speech recognition technology approach at HIMSS, one that focused on documentation and workflow management. Provox chose HIMSS as the venue to announce its VoxNotes software for PGPs. Provox is the newest member of the growing VoxEnterprise family of solutions, with this orders-based medical documentation management system. If this last task can be done well, it essentially automates the dictated input side of collecting structured medical records for the EHR.

The ultimate goal of the EHR, apart from those of making records accessible when needed and point-of-care decision support, is to determine "best practices" so that an evidence-based medicine approach can ultimately be defined, validated and adopted. However, without a standardized manner for all providers to define disease, interventions and outcomes, the ultimate goal cannot be achieved. Only to the extent that the structuring is properly done on the input side will the information collected be easily and efficiently retrievable later on. Many approaches to front-end data capture and automation offered by vendors are unfortunately coupled with much weaker indexing and back-end storage solutions. It's not the type of database software, be it Oracle, Sybase, SQL-server, etc. that counts, but the organization of the application (level 7) knowledge that is impressed on the DBMS structures. Lack of the incorporation of structured vocabularies and indexed outcomes is a major differentiator of rival EHR solutions available in the market today, particularly those that accept freeform text rather than using pick lists or other structured approaches. Yet speech recognition is attractive to physicians in the early stages of converting paper-based systems to EHRs because they impose such little change in current practice to use them.

Speech recognition solutions capture medical information in freeform, structureless blobs. Products like those offered by Dictaphone, Provox and others who take the extra step of indexing the captured and transcribed voice data are significant steps forward because they process such blobs into structured data that can then be stored and easily retrieved later on. Dictaphone and Provox provide excellent solutions for physicians looking to move into the EHR without making major changes in their style of practice. Starting with a patient scheduler which alerts the physician to who is being seen, Provox automates the dictation capture and SRT piece, delivering both the audio and translated text in a synchronized version for editing. After physician review, the record is electronically signed compliant to requirements of CMS or Joint Commission on Accreditation of Healthcare Organizations (JCAHO; Oakbrook Terrace, Illinois) and faxed off to the referring physician or archived into the VoxAdministration EMR archive module. The product also includes a "Rules" engine called SmartMacros. So far, Provox has been used and customized for 33 different PGP practice specialties according to company data. Dictaphone has the advantage of being a name that physicians know and associate with dictation, and the company has capitalized on that recognition. Dictaphone has designed products so that physicians do not need to change how they enter data, even though now the back end is HER-oriented and contains structure in the form of terminology and rules.

The American Health Information Management Association (AHIMA; Chicago, Illinois) was present at HIMSS, promoting speech recognition as a vital part of the EHR, saying, "the electronic health record (EHR), when coupled with speech recognition, may provide the ideal combination of flexibility, convenience and efficiency for healthcare organizations." Additionally, SRT may be the key to making healthcare clinicians and medical transcriptionists more productive participants in the documentation process, enabling them to keep pace with demands. "SRT used directly by the physician-dictator, in conjunction with the HER . . . becomes a viable option in the face of decreasing reimbursement, rising costs, growing labor shortages and increasing demands for more complete documentation provided in a more timely manner," according to Harry Rhodes, director of health information management at AHIMA.

Oh, Brother! One company understands

Even with transcription, the need for paper will not soon disappear, and while it remains, the need for office copiers, fax machines and scanners to send and receive referral reports and other medical documents also remains. Many of the traditional office equipment suppliers have generally missed the specialized security and other needs of the medical vertical market, particularly at the budget end of their product lines. However, Brother International (Bridgewater, New Jersey) is one office products company that has understood the unique needs of the medical vertical market and designed a range of products to meet them. New as a vendor for the first time at HIMSS, Brother's booth showcased an impressive array of printers, copiers and scanners all designed to provide special features of interest to medical clients. For example, such security features as password-protected printing have been integrated into some of their fax and combination devices, allowing received faxes to be retrieved and printed only when the individual they are intended for authenticates themselves to the machine with a password. Until then, the data is kept encrypted on an internal fixed drive, secure from being intercepted by passersby or other unauthorized persons.

Modems integrated in most models were 33.6K, which means shorter transmission times when talking to similar machines at the receiving point. Coupled with secure scanning and password-protected printing and faxing, the capabilities of these Brother products are a major step forward in securing paper medical documents, providing a needed and vital link in the chain of HIPAA security for handling remaining paper documents.

The other impressive capabilities of the Brother office products we saw were the number that accepted wireless network inputs. These would be ideal for wirelessly enabled healthcare providers who are using tablet- or pen-based PCs, or wireless PDAs in their offices and need an easy way to obtain document printouts while walking around or working wirelessly. Many models also duplexed or handled duplexed documents, saving labor and cost. Not only were such capabilities unusual in office machines, but the aggressive pricing of Brother products coupled with their low supply and other lifecycle costs made them the hands-down choice for smaller, cost-conscious group practices in need of hardwired or wireless, network-enabled, HIPAA-compliant office equipment, coming in some 30% below competitive but higher-priced models offering similar or lesser capabilities. These products are not just for PGPs, however; hospitals also will be very interested in the cost benefits of these products. So while the busy doctor still may opt for a high-priced IPAQ PDA, he or she is likely to be using it with a less-expensive Brother printer, scanner or fax machine unless money is no object.

AnyDoc Software (Tampa, Florida) was showing its latest document and data capture software that provides automated solutions for creating electronic data interchange (EDI) documents required by HIPAA. They extract data from incoming healthcare forms and reports, according to Charles Jackson, AnyDoc president, and supply EDI as the output, enhancing billing operations for HIPAA-standardized 835 and 837 transaction formats.

New products make their debut

While the ranks of the would-be EHR systems for smaller practices have thinned a bit, HIMSS remains a showcase for new products. Bizmatics (Cupertino, California) was one of the new, small vendors making its EHR debut at HIMSS. The company was started by former Silicon Valley engineers working in conjunction with several physician advisors. The system that resulted was yet another well-conceived but not fully mature EHR product, called PrognoCIS, targeted at physician group practices ranging from three to around 20 physicians. Practice specialties already using this solution include: cardiology, urology, dermatology, internal medicine and others. Bizmatics is live at three sites and will go live shortly at seven more. Unlike some of the systems from smaller vendors, this system has a fully integrated drug information and interactions database, which it licensed from First Data Bank (San Bruno, California), one of three or four vendors of such knowledge bases. Bizmatics also was working on a scanning option that allowed existing paper records of patients to be scanned in and attached to the current electronic encounter file of new patients seen after a practice goes electronic. This provides a gradual means of working down the practice's file room in a manageable fashion as existing patients of the practice are scheduled for new appointments. The product is a web-browser solution that can run off a Microsoft (SQL) or Linux-type/ Apache (MySQL) webserver and database. The front end is an all-Javascript solution that leverages the capabilities of the Microsoft Windows+Browser platform. The system displays E/M levels and passes data directly to interfaced VantageMed and Advanced Med practice management systems using HL7 and custom messaging. PrognoCIS also provides lab connectivity using HL7. At a cost of around $8 per provider, this is one of the more inexpensive EHR solutions we encountered on the HIMSS floor.

Chartcare (Lakewood, Washington) was touting its "America's Best" KLAS rating at HIMSS, offering an EHR also targeted for PGPs of less than 25 physicians. One of the strengths of Chartcare is its strong security and privacy features, according to Dennis Niebergal, company president, who talked about systems running on its in-house servers. Chartcare has been developing ambulatory solutions for physician group practices since its founding in 1984. Chartcare offers a variety of secure email services as well with its IServer system.

MediNotes (West Des Moines, Iowa) was another EHR vendor targeting smaller to mid-sized physician group practices with its Charting Plus 4.4 product. One of the slicker features of Charting Plus is its interface with Primetime's Instant Medical History program, which interviews patients and exports the data to Charting Plus. Another is the ability to include images in the EHR. The product's security manager provides for secure remote access to caregivers, and its drug interactions modules provide a useful safety net. This may be an excellent choice for PGPs already using transcription services that desire to move into a true EHR.

HIMSS also provided a venue for announcements of large deals. Allscripts (Libertyville, Illinois), a major EHR vendor, used the meeting as the occasion to announce its new partnership with the State University of New York College of Optometry (New York) and its clinics. This group selected the TouchWorks EMR for use by its physicians. This EMR will be integrated with the existing IDx Systems (Burlington, Vermont) practice management system, adding electronic prescribing, charge capture, electronic ordering and clinical notation functionalities.