About a month ago, I started researching medical IT. Before now, my background has been in what I’d call IT for IT professionals. Recently, I’ve felt a need to contribute to society in a more meaningful way. I’ve never really spent much time looking at healthcare until now.
The first area that caught my eye was software around Electronic Medical Records (EMR). An EMR solution will generally try to record all things related to a patient in a hospital or doctor’s office (ambulatory + acute care and others). Frequently EMR is also used as an umbrella term to include other specific categories of software such as Revenue Cycle Management (RCM), Admin & Practice Management (PMS) and more specialized clinical functionality. The problem it solves tends to be different depending on who is using it. For example, at a hospital EMR might track what prescriptions have been administered to a patient in and seeing a single list of prescriptions in an EMR can help physicians quickly identify issues. Another use would be to track all the diagnoses and interventions taken by a doctor for submission to insurance companies.
My first realization was that EMR is actually a very broad set of solutions. It does very different things for different types of organizations. For example, a large HMO such as Kaiser has very different need than that of a small 10 person practice – but both can benefit from the digitization of medical records (from say a paper based system).
Below are my first reactions to specific software offerings I’ve found that are of interest.
Low Cost, ‘New’ EMR
In particular, two companies stood out to me here: Practice Fusion and Dr. Chrono. Both companies have launched their first low-cost/ free EMR products in the last 5 years and I would describe them as different from the traditional software in this space. While many other new EMR companies target specific types of practice – these two companies seem to aim at providing all practices a baseline EMR solution. If I were to guess, each of these company’s main customer has less than 100 physicians in its office. I’d also guess that these companies mainly address ambulatory care (e.g. regular doctors office) rather than acute care (hospitals etc).
In terms of total usage – it’s hard to guess. Dr. Chrono just yesterday sent out an email to all it’s users stating they have 35,000 doctors using their product. I’m a little skeptical of this number myself as I’m not a doctor yet am signed up for the service since its free to try (and I’m willing to bet I’m counted as one of those 35,000 doctors).
I have more to research in this area. I’m particularly curious to learn how many doctors practice ambulatory care total and how many currently use software like Dr. Chrono on a daily basis.
Epic, Cerner, McKesson and others
Epic is a privately held company building mainly EMR technology, consulting, enterprise types of customization and training. They had an estimated $1.2B in revenue in 2011 according to Wikipedia. Cerner is a publicly traded company who sell a number of software and services related to EMR and other hospital related systems. The selling point of these company’s software are their ability to plug in and manage every part of a hospital. Smaller EMR companies can’t afford the cost of supporting as large a system that is as highly customizable.
The general reaction I’ve heard from doctors is that the software from these types of companies is pretty bad from a usability perspective. Some doctors I’ve talked to say that the usability is so bad that it compromises the value of having EMR at all.
This software seems to be pretty typical Enterprise Software. The companies selling this software frequently seem to be plugged into hospitals in a big way. And this goes beyond software. Training and certification programs mean that nurses and others take weeks to become skilled power users of the system – the cost to retrain is very high. The data formats used by the software are largely unstandardized and undocumented – transitioning old data is near impossible unless you have relatively large budgets to move (order of magnitude seems to be as high as deploying and training in the first place – this can cost $100s of millions).
My impression is that once a hospital commits to software like this, it’s nearly impossible to move away from it. The value of this software comes from the total integration of many different departments and functions and Cerner’s + Epic’s ability to customize the product to the workflows of the specific hospital systems.
Veterans Affairs (VA) EMR
The Office of Veteran Affairs open sourced their EMR solution in 2011 (http://www.va.gov/opa/pressrel/pressrelease.cfm?id=2153). Even before the press release, the Freedom of Information Act (FOIA) was used to successfully request copies of the software. OSEHRA (www.osehra.org) was started to be a place where interested parties could contribute to the project.
The VA is the largest medical system in the US by revenue. Back in the 80s the VA started to create the EMR solution that eventually became VistA. VistA is comprised of 160 different sub-modules including scheduling, basic notes, pharmacy management, imaging, billing and many others. Despite the open sourcing of the project I’m guessing there are very few organizations outside of the US Government that make use of VistA and related packages today. I would say there are 3 big reasons why this is the case:
- The open sourced VistA is very much so specific to the VA. E.g. patients have records on if they are still in active duty and what their agent orange registration number is. In addition, it seems the billing components for the VA are dramatically different than most other hospitals.
- There is no company offering a high enough level of enterprise support. The VA’s system is frequently cited as being one of the best EMR solutions out there, but hospitals still need support in terms of training, operating and transitioning from existing systems. Without this, deploying VistA would be very daunting for any hospital/ care provider.
- No single source of information exists to setup all components related to VistA. Information is spread between hundreds of documents and despite the OSEHRA website, I still think there is no centralized authority on Vista setup/ operations/ training materials.
This said there are still many interesting efforts to keep an eye on in regard to VistA. Namely, there are forks of the Vista code such as WorldVista and companies such as Astronaut VistA who are trying to make the VA’s award-winning EMR solution more approachable.
In the coming months, I’ll be trying to identify how I can improve healthcare given my background. Given the importance of EMR I’m sure it will be a repeating theme.
EMR is a very fragmented today. I’m starting to see it as a much more nebulous concept than I first thought it to be. There are hundreds of dramatically different EMR solutions for different types of practices + hospitals. This said, while EMR technology has a long way to go, it is clearly improving the quality of care across the board.