BBI Contributing Writer

BOSTON, Massachusetts – Physician offices, hospitals and payers who were seeking solutions to improve the quality of care, contain costs, reduce medical errors, as well as meet Health Insurance Portability and Accountability Act (HIPAA) requirements, converged on Hynes Convention Center in Boston's trendy Back Bay for the Medical Records Institute's (MRI; Newton, Massachusetts) 17th annual TEPR (Toward an Electronic Patient Record) conference. With in excess of 5,000 conference attendees and more than 150 exhibiting vendors, TEPR was a reality check on progress in achieving an electronic patient record (EPR) system.

One observer, after surveying the exhibit floor, the different systems available to her and the rapidly changing technology that keeps software companies "always developing, seldom selling," noted that there "is a reason this conference is known as Towards an Electronic Patient Record." She wryly noted: "Once they drop the 'Towards' and it is known as the EPR conference, then I will feel like it is time to buy." This comment underscores some of the resistance met in trying to reach the ultimate goal of computer-based medical records. Industry analysts at the show were predicting that this ultimate goal of a paperless health system was still five to 10 years away, regardless of newer regulations such as HIPAA driving system change and adoption.

Communication frustration between customers and vendors was one reason cited for the slow progress. With physician practices and hospitals frightened by implementation horror stories, there are fewer pioneers and a growing number of late adopters, as prospects remain cautious about the real benefits of these systems. There were whispers from physicians about vendors promising anything to stay in contention for business, and vendors wishing for the ideal customer who knows exactly what system capabilities he or she wants up-front and does not become disillusioned as contract talks progress. To underscore the observer's comment, it looks like it might be a while before we can drop the "Towards."

Preliminary survey results from the 2nd annual survey of EHR trends and usage sponsored by MRI showed that the biggest drawback to deploying a computer-based system continues to be the cost of implementation. There are two components to this cost – hardware and software. Hardware costs have dropped dramatically each year. Ten years ago a state-of-the-art system with a 150 MHz 80486 CPU, 10 gigabytes of hard disk space and 64 megabytes of memory cost over $2,500. Today, a 700-800 MHz Pentium III CPU with 128 megabytes of memory and a 30-gigabyte hard drive costs less than $1,000.

Software development costs should also be dropping. The availability of Java and web-enabled tools, wireless, thin client server products embedded in the Windows 2000 operating system, as well as standards such as HL7 implemented as middleware should make software development costs drop. However, system costs still remain "too high," according to many prospective customers. One reason is that the application "solution" is never static and never achieved. Instead, all vendors constantly have to change their systems – first for Y2K, then HIPAA, then to do pathways, then to catch medical errors ... and it never stops. Meeting legal/accreditation standards, improving clinical documentation and containing costs are also contributing factors driving the market move from paper to electronic records.

Highlighting the interest in EMRs were the 1,000+ attendees present for the Clinical Documentation Challenge, in which 11 leading vendors demonstrated their system by documenting a simulated doctor/ patient encounter. Among those demonstrating were larger, well-known companies such as +Medic (Raleigh, North Carolina), Siemens/SMS (Malvern, Pennsylvania) and Epic (Madison, Wisconsin), as well as a handful of upstarts such as Noteworthy (Cleveland, Ohio), PenChart (New York), and e-MDs (Cedar Park, Texas).

The focus at this year's conference was on the physician office rather than the hospital inpatient settings. Most of the systems geared toward the physician practice offered similar features, with data presentation and price tags differentiating them. For example, almost all the physician group practice EMR vendors were offering a fully integrated product that documented patient encounters, kept track of messages, lab results, patient demographic information, wrote prescriptions and provided some sort of data mining capabilities. Most of the systems run on Windows, supposedly enabling a quick learning curve and providing a scaleable solution. It was the little things that set systems apart from one another. Therefore, with such poorly differentiated "commodity" solutions, it may be the wrong feature set or insignificant product advantages that will determine which vendors make it, and which ones will be forced out of the market.

Electronic patient records

After announcing last November that it would be partnering with A-Life Medical (San Diego, California) to integrate A-Life's Lifecode technology into its Novius product, standout Siemens/Shared Medical Systems (SMS) demonstrated a new billing software that uses natural language processing. This product goes beyond just looking for key words within the dictated notes, it looks at the way words interact to impart meaning. Siemens' system is "voice engine" neutral, working equally as well with Dragon's (Burlington, Massachusetts) NaturallySpeaking, ViaVoice by IBM (Armonk, New York), Philips (Amsterdam, the Netherlands) or Lernout & Hauspie (Burlington, Massachusetts) systems. After the physician dictates the patient encounter into the system, "best match" billing codes are returned automatically, based on the dictation and taking into account the clinical context. For example, if the physician dictated that the patient's ankle was sprained but not broken, the system would return the code for a sprained ankle but not a broken one. Likewise, "contusions to the back of the hand ..." and " ... knife in his back" would return separate codes. This voice recognition/natural language processing technology is particularly interesting because a physician now can dictate all the information he wants in the chart. No longer constrained to select only phrases from a predefined, drop-down options menu, the physician will receive "smart" coding responses back in a matter of seconds after dictating. The best human coders have been shown to disagree with each other on a regular basis. Using a system such as this, where coding is more than 90% accurate, cuts down on manual coding costs. The SMS system improves revenues by avoiding undercoding that results in lower reimbursements. It can also catch overcoding errors, which can create a potential audit/repayment issue and consume enormous amounts of office staff resources.

Another EMR vendor on the move is +Medic. With more than 12,000 installations and 70,000 physicians using its software, +Medic is the leading supplier of physician practice EMRs. Proving the company was not merely content with its current product, +Medic Tiger was introduced last year and since has proven to be a versatile product. A true Windows-based system, Tiger's standout features include an easy-to-use appointment scheduler with a five-doctor simultaneous view, perfect for organizing a larger practice. It is easily customizable to fit most practices' needs, and a query tool allows users to create their own customized reports without needing to know SQL or other database query languages. Recently +Medic has rolled out Firsthand, the first in a series of mobile applications under development. Firsthand allows providers to view their appointment schedule, patient information and billing codes, and captures charges at the point of care. Users simply synchronize with the system when they return to the office. Firsthand is not a complete wireless system, but an extension of existing products; however, this move may be a signal that +Medic may someday become a serious player in wireless EMRs.

Wireless, handheld EMR systems offer greater flexibility in the office than stationary workstations, allowing users to easily enter data at the point of care. Wireless systems allow the physicians to focus less on the computer and more on the patient if the systems are properly implemented. Penchart, a part of Pfizer Health Solutions (also New York), is one such wireless solution designed for wireless tablet computers. With roughly 50 installed sites servicing 500 providers, Penchart is designed for specialty practices. Like +Medic, Penchart provides customizable templates for specific types of practices. Penchart also includes a handwriting-to-text function that is helpful in a touch-screen environment. It also uses a dictation function that allows the physician to capture extra information not available using the drop-down lists, which when transcribed, becomes a part of the medical record.

JMJ Technologies (Marietta, Georgia) is one of the smaller vendors that seems to be growing and succeeding in the physician office EMR space. Its EncounterPRO system uses touch-screens on laptop, desktop, or pen computers. It is a client-server approach, and can use wireless thin client platforms (Microsoft Windows NT). A first-place finisher in last year's TEPR awards, JMJ's EncounterPRO contains a front-end medical coding engine and relational database to facilitate research and analysis. EncounterPRO has an open-systems architecture and has been adopted to several clinical specialties. Of the physician office EMRs exhibited at TEPR, EncounterPRO was one of the strongest products, offering an excellent mix of features and new technology integration. Innovative technology, such as voice recognition or window terminal server (thin client/server implementation), requires a lot of processing power, which means a significant hardware investment.

Notably missing from the EMR vendors in Boston was Medscape (Hillsboro, Oregon), whose Logician product is one of the more widely recognized and used systems. More than one rival vendor was quick to point out the missing Medscape and mention the company's lagging stock price. Medscape was previously known as Medicalogic, before the acquisition.

HIPAA challenges

With the growing security requirements of the HIPAA legislation, the question is what technology is going to be used to protect medical records from being seen by the wrong people or inadvertently disclosed?

For all the buzz surrounding biometric authentication, it was Ensure Technologies (Ann Arbor, Michigan) and its XyLocMD Wireless Security Solution that took top security systems honors at the 2nd annual TEPR awards (Table 3). XylocMD is a completely hands-free, noninvasive solution where no fingerprint, voice verification, passwords, etc., are needed. It is a proximity-based product that detects when an authorized user is within a set distance from the workstation. When an authorized user is within the zone, the workstation is unlocked. More importantly, when an authorized user is not within that set area, the workstation is automatically secured. As a member of the Bluetooth Special Interest Group, Ensure and its security system will also be available to authorized users of Bluetooth-enabled PDAs, PCs and phones as well.


For those users fearing passes would be lost or stolen, compromising security, BioID (Raleigh, North Carolina) has another solution. BioID is different from other biometric recognition solutions in that it does not rely on one single method of authentication. Rather, it is designed to recognize users by checking three personal traits: face, voice, and lip movement. If all three trait thresholds are set so that any of the three traits may incorrectly recognize the user only 1% of the time, the possibility that someone could be misrecognized by all three methods at once could be as high as 1 in 1 million. The costs could be relatively high for this solution, depending on how many PCs need to be protected. The only hardware items needed are a standard videoconferencing camera and microphone, which can be purchased for around $100. It doesn't sound too high, but compound that $100 over 200 PCs that need being secured and you are already talking a $20,000 investment on hardware alone.

Internet connectivity

Also receiving top honors in the TEPR awards in the category of Internet connectivity was VitalCom (Tustin, California), now part of Data Critical, for its PatientBrowser, an integrated part of PatientNet, a real-time open and wireless information network for patient vital signs data in hospitals. PatientBrowser allows caregivers to view vital sign information on their patients in real time, using a web browser and a secured internet/intranet connection. With intelligent software that analyzes the physiological data received, technicians are able to weed out false alarms, which frees up nurses to focus on patient care. What makes VitalCom's solution unique is the fact that it can be used not only with its own patient-worn transmitters, but also with many other patient monitors on the market. Such mixed-system approaches raise interesting liability concerns if an event is missed however, as two different vendors' systems would be involved, and each would potentially blame the other for the problem. PatientBrowser operates in the new, 608-614 MHz band (WMTS) set aside for medical telemetry. It can connect more than 500 patients on a single network. It has built-in graphical user interfaces that presents a consistent look for the data regardless of the originating device, and also allows the data to be captured as part of a patient's permanent clinical record.

TEPR showcased both the rapid pace of evolution and even more rapid change in the requirements for a viable electronic medical solution. The question remains, will the EMR vendors ever be able to overtake the pace of medical and legal EMR requirements? The companies left standing at the end might not necessarily be the vendors with the "best" product on the market today, but the ones that are able to adapt to the needs of an ever-changing marketplace.

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