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EHR Usability: Is There a Right Path?

Note: This was also a guest publication on emrandehr.com

Earlier this fall, the AMA sponsored a Rand Corporation study on physician’s professional satisfaction. Based on interviews with physicians in 30 practices, the study covers a variety of topics from workplace setting to quality of care, EHRs and health reform, etc. At the time, the report generated discussion about dissatisfaction in general with EHRs and MU in particular.

Usability, Part of MU?

Overlooked in the discussion was a new and important recommendation on usability. Here’s what it says:
Physicians look forward to future EHRs that will solve current problems of data entry, difficult user interfaces, and information overload. Specific steps to hasten these technological advances are beyond the scope of this report. However, as a general principle, our findings suggest including improved EHR usability as a precondition for federal EHR certification. (Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy, p.142) Emphasis added.
It would be overkill to say that this represents adopted AMA policy, however, it’s not overkill to say that the recommendation is part of a project that the AMA initiated and supports. As such, it is most significant that it recognizes the need to bring some coherence to EHR usability and that the MU system is the logical place to put it.

Changing the Vendor – User Relationship

One commentator who did notice the recommendation was EHR Intelligence’s Robert Green. In his review, Green took a different tack. While agreeing that usability needs improvement, he saw a different way to get change:

Usability remains an enigma in many clinic-EHR vendor relationships because it hasn’t been nearly as important in the recent years’ dialogue as “meaningful use.” But among the competing priorities, usability among physicians and their EHR vendor is a real opportunity to develop shared expectations for a new user experience.
As a patient, I would rather not see the delegation of the “usability” dialogue of EHR to those in the roles of meaningful use certification. Instead, physicians who have spent many years of their lives learning how to “take care of patients” could seize the moment to define their own expectations with their EHR vendor of choice within and beyond their practice. (How connected is EHR user satisfaction to vendor choice?) Emphasis added.

I think these two different paths put the question squarely. They agree that usability needs increased action. Users have gotten their message across with alacrity: all systems fail users in some aspect. Some fail catastrophically. Though some vendors take usability to heart, the industry’s response has been uneven and sporadic.

Where these two approaches differ is tactics. Rand looks at usability, and sees an analog to MU functions. It opts for adding usability to MU’s tests. Green sees it as part of the dialogue between user and vendor.

As a project manager and analyst, my heart is with Green. Indeed, helping users find a system that’s a best fit is why we started the Selector.

Marketplace Practicalities

Nevertheless, relying on a physician – vendor dialogue is, at best, limited and at worst unworkable. It won’t work for several reasons:

  • Nature of the Market. There’s not just one EHR market place where vendors contend for user dollars, there are several. The basic divide is between ambulatory and in patient types. In each of these there are many subdivisions depending on practice size and specialty. Though a vendor may place the same product name on its offerings in these areas, their structure, features and target groups differ greatly. What this means is that practices find themselves in small sellers’ markets and that they have little leverage for requesting mods.
  • Resources. Neither vendors nor practices have the resources needed to tailor each installation’s interface and workflow. Asking a vendor, under the best of circumstances, to change their product to suit a particular practice’s interface approach not only would be expensive, but also would create a support nightmare.
  • Cloud Computing. For vendors, putting their product in the cloud has the major advantage of supporting only one, live application. Supporting a variety of versions is something vendors want to avoid. Similarly, users don’t want to hear that a feature is available, but not to them.
  • More Chaos. Having each practice define usability could lead to no agreement on any basics leaving users even worse off. It’s bad enough now. For example as Ross Koppel points out, EHRs record blood pressure in dozens of different ways. Letting a thousand EHRs blossom, as it were, would make matters worse.

ONC as Facilitator Not Developer

If the vendor – buyer relationship won’t work, here’s a way the MU process could work. ONC would use an existing usability protocol and report on compliance.

Reluctance to put ONC in charge of usability standards is understandable. It’s no secret that the MU standards aren’t a hands down hit. All three MU stages have spawned much criticism. The criticism, however, is not that there are standards so much as individual ONC’s standards are too arcane, vague or difficult to meet. ONC doesn’t need to develop what already exists. The National Institutes of Standards and Technology usability protocols were openly developed, drawing from many sources. They are respected and are not seen as captured by any one faction. (See NISTIR 7804. And see EMRandEHR.com, June 14, 2012.)

As I’ve written elsewhere, NIST’s protocols aren’t perfect, but they give vendors and users a solid standard for measuring EHR usability. Using them, ONC could require that each vendor run a series of tests and compare the results to the NIST protocols. The tool to do this, TURF, already exists.

Rather than rate each product’s on a pass – fail basis, ONC would publish each product’s test results. Buyers could rate product against their needs. Vendors whose products tested poorly would have a strong incentive to change.

EHRs make sense in theory. They also need to work in practice, but don’t. The AMA –Rand study is a call for ONC to step up and takes a usability leadership role. Practice needs to match promise.

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Dan Bricklin: Still Productive After All These Years

If you ever used Excel or Google’s spreadsheet, you owe Dan Bricklin a thanks. In 1978, Bricklin had the idea to automate table creation. Along with fellow programmer Dan Fylstra, Bricklin worked out the program’s layout, commands and internal routines on a 40 column Apple II. They called it VisiCalc and it spawned the first real business interest in microcomputers. Here’s what that first screen looked like.

Visicalc

The appeal to business was simple. Put in a what if number and you instantly saw the result. Moreover, until then if you made a table you had to spend much time doing footings, that is, making sure that the vertical and horizontal totals agreed. VisiCalc did that for you, eliminating time and errors.

Bricklin, unlike many of the other PC pioneers did not go on to build a large company, etc. Instead, he has founded small businesses focused on innovations in user design and applications. Most remarkable, he’s never lost his touch for user views and usability.

So, what’s this got to do with EHRs? Much. Below is Bricklin’s take on designing apps and sites that use different platforms and OS. In it he moves quickly from automating spreadsheets to today’s challenges, including what to do with left-handed users on tablets.

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When Things Go Wrong, The Caterer Gets The Blame

This note was published as a guest article on Shahid Shah’s Healthcareguy.com blog.

From Shahid: Carl Bergman, a seasoned systems analyst and project manager, is Managing Partner of EHRSelector.com and has been sharing a number of ideas for improving EHR usability with me via email. Since I loved his enthusiasm and agreed with his ideas, I invited Carl to share with us some more detail around how to improve the EHR user experience. Here’s what Carl had to say:

Earlier this year, we went to an outdoor wedding. It was wonderful. The weather, the bride, the ceremony and the food that followed were all great. Curious, I asked the caterer how she did it. Here’s what she told me:

“We do dozens of these a year, most go really well, like this one. Some not so well. When that happens, I’ve learned one thing. Whenever things go wrong, no matter who’s at fault, I get the blame. It doesn’t matter if the florist screwed up the flowers, the venue failed to turn on the PA or the rental company delivered the wrong chairs, I get blamed.

‘“So a long time ago, I decided that if I was going to get blamed, I’d just assume that I’m in charge of everything. I tell my clients, not to worry. I’m their coordinator and will move things along, so they don’t need to worry. They love it and it’s in my interest.”

It’s a good lesson for anyone serving cake or building a system. Complaints about EHRs’ user interfaces are rife, but few detractors bother to differentiate among the product, implementation, support or user problems. Regardless, the developer gets the blame, even if you did nothing wrong, so you just as well turn it to your advantage.

There are several things, some counterintuitive, that you can do to head off problems, improve user satisfaction and avoid complaints. As with the caterer, the first thing is to assume you are in charge of making things go well. More specifically, taking steps such as these:

Developing for Usability

  • Define the Problem. Vendors and their developers may believe they know their product’s I/Fs, but when pressed many have only anecdotal knowledge. Fortunately, there are objective ways to document how your EHR performs. As I’ve noted in other posts, the University of Texas Health Science Center, National Center for Cognitive Informatics and Decision Making (NCCD) free tool, TURF, is a versatile app for documenting and analyzing EHR performance. It shows how users work with EHRs. It also lets you compare that behavior to the National Institute of Standards and Technology’s EHR usability protocol 7804.
  • Sunk Cost and Cash Cows. Vendors whose products are selling well are loath to mess with success. It’s not easy to recognize that what works today may fall behind. However, vendors need to recognize that usability shortcomings will take a toll and endanger both their investment and returns.
  • Aware Development. It’s no secret that development teams are often closed shops. Adding UI/UX specialists, if not already on the team, is an important step. Equally important is keeping the team focused outward. Given that many EHRs are the child of one clinician’s vision, it is often difficult to insure that the team sees beyond the initial vision to include others’ ideas.

Let the Message Through

  • Agreements. Your company lawyer did a great job of protecting you from being sued. Are you so protected, though, that your client can’t talk about problems? Client complaints may be on target or way off, but if they are afraid to tell you or discuss it with anyone, how will you know?
  • User Groups. If you don’t have a formal way for your users to discuss problems and solutions, start one. Even if you have one, if users have started their own, does it cover topics you’ve avoided?
  • Support. Years ago, WordPerfect required each of their execs to spend a day manning their help line. Today, there are many ways to communicate with users, but spending time fielding support issues can give you a feel for your users’ concerns. It can also tell you not only how your support system is doing, but also if it’s passing important issues up the line.

Implementing for Success

  • Participation. Implementing an EHR within an existing environment often builds in problems you can’t control, but have to work with. Even if the client acknowledges that the EHR will face several hurdles, in the end it won’t matter if they are unhappy. To protect yourself, you make sure that others are at the table who understand and can act to overcome these problems. This means building an implementation group that includes those who will actually use the system or pass it data, such as clinicians, nurses, health techs, etc.
  • Customization. It’s a rare install that doesn’t require tailoring a system’s I/F to client needs. Customization doesn’t end with a go live, but continues through out the system’s life. Even if you’ve worked hard to insure that customized screens, etc., are useful and useable, after turnover it’s another game. Insuring the quality of follow on work after you’re done is not easy. However, you can hedge your bets by making an offer your client can’t refuse. As part of your support, come back each year to review the system. Put in any missing upgrades, etc., and give your client a punch list of issues and changes.

As with the caterer, EHR vendors face a number of problems not of their own making, but can still bite them. However, like the caterer, product vendors should take charge of their process and realize that usability may not be in direct demand, but over time can make or break the company.

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November: Open Season for EHRSelector Vendor Profiles

Notice: Vendors listed on EHRSelector.com or those that want to be listed, November is open season for you to update your product profile or submit a new one.

Vendors currently listed on the Selector are:

NoVendor Product
1AllscriptsAllscripts - Enterprise
2AllscriptsProfessional
3AllscriptsSunrise Ambulatory Care
4Aprima Medical SoftwareAprima EHR + PM + RCM
5ChartLogicChartLogic EMR
6Clinical Computer SystemsOBIX
7Clinix MISClinixMD
8CureMD CorpoprationCureMD EMR
9DocPatientNetworkDoctations
10e-MDse-MDs Solution Series
11GE HealthcareCentricity Advance
12GE HealthcareCentricity EMR
13gMedgGastro
14Greenway Medical TechnologiesPrimeSuite
15iSALUS healthcareOfficeEMR
16McKessonInteGreat EHR
17McKessonPractice Partner
18mdonlineInSync
19NextGen Healthcare Information SystemsNextGen® EMR
20OptuminsightOptum Physician EMR
21Pulse SystemsPulse Patient Relationship Management
22SynaMedSynaMed
23Trimed Technologiese-Medsys EHR
24Vitera Healthcare SolutionsVitera Intergy EHR
25XciteEncounterPRO

To update your profile, log into your Selector account. To submit a product profile, go to the Selector”s home page, Vendor Registration. For help with any Selector issue, contact:

Info@ehrselector.com or call 202 291 8212.

The Selector

The Selector is free for both users and vendors. There is no advertising. It has no backdoor relationships with vendors. Currently, there are about 25 vendors.

Vendors product profiles cover about 350 features. Major topics include:

  • Contract details
  • Medical specialties
  • Practice size
  • First year license cost
  • eRx functions
  • Integration of ECGs, labs, etc.
  • Interface, operating system
  • Medical record content
  • Problem list
  • Reporting capabilities
  • Standards include CCHIT, HIPAA, LOINC, etc.
  • Security, privacy

Using the system to find an EHR is easy. Clicking on one or more EHR features instantly tells you how many products match. You can then generate a full side by side report of the qualifying vendors.

We take several steps insure the integrity of submissions, for example, we only accept features that are either installed in a practice or fully available.

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TURF: An EHR Usability Assessment Tool

Note: This was also a guest publication on emrandhipaa.com

To paraphrase Mark Twain, everyone talks about EHR usability, but no one does anything about it, at least until now. Led by Dr. Jiajie Zhang, the University of Texas Health Science Center at Houston’s National Center for Cognitive Informatics and Decision Making (NCCD) has developed several tools for measuring usability.

Now, Zhang’s team at NCCD has put several EHR usability tools into a Windows based app, TURF, an acronym for Task, User, Representation, Function. Funding for the project comes from ONC’s Strategic Health IT Advanced Research initiative.

TURF’s Tools. TURF has two major tools, Heuristic Evaluation and User Testing:

  • Tool One. Heuristic Evaluation: Expert Screen Capture and Markup. This tool takes EHR screen snapshots and let you compare them to usability standards. You can markup the screen and document the problem.Turf Expert Markup Tool - Showing Problem and DocumentationFor example, you can note if the error is minor, moderate, major or catastrophic. The system has a review function, so others can look at your markup and comment. The system also compiles your edits and can generate various statistics.
    • Administration. To work with groups, the system has several preset admin template forms and a template editor. The furnished templates cover these areas:
      • Demographics
      • Expert Review
      • Performance Evaluation, and
      • System Usability. This form asks 10 questions about the EHR, such as:
        • I think I would like to use the system frequently,
        • I thought there was too much inconsistency in this system,
    • Standards. The system uses the National Institute of Standards and Technology’s (NIST) EHR usability protocol, NISTIR 7804. You may also add your own rules to the system. (Also, see EMRandEHR.com, June 14, 2012.)
    • EHR Sections. Using the NIST protocol, the system’s review areas are:
      • Clinical Decision
      • Clinical Information Reconciliation
      • Drug-drug, drug-allergy interactions
      • Electronic Medical Administration
      • ePrescribing
      • Med – Allergies
      • Medications list
      • Order Entry
      • User defined
  • Tool Two. Live Session Testing. TURF’s user test tool sits on top of an EHR and recording each movement. TURF’s designers have created a system that not only tracks use, but also adds these major functions:
    • User Sessions. TURF captures live screens, keystrokes, mouse clicks and can record a user’s verbal comments in an audio file.
    • Administration. The tool is designed for testing by groups of users as well as individuals. It captures user demographics, consent forms, non disclosures, etc. All of these can be tailored.
    • Testing for Specifics. TURF allows managers to test for specific problems. For example, you can see how users eprescribe, or create continuity of care documents.
    • Comparing Steps. Managers can set up an optimum selection path or define the steps for a task and then compare these with user actions.
    • Reporting. TURF builds in several counting and statistical analysis tools such as one way ANOVA.
  • Running TURF. TURF isn’t your basic run and gun app. I downloaded it and then tried to duff my way through, as I would do with most new programs. It was a no go. Before you can use it, you need to spend some time setting it up. This applies to both its tools.Fortunately, TURF has about 30 YouTube tutorials. Each covers a single topic such as Setup for Electronic Data Capture and runs a minute or so. Here’s what they cover:Turf Tutorials Screen
  • Hands On. Installing TURF was straightforward with one exception. If you don’t have Microsoft’s .Net Framework 4.5 installed, put it up before you install TURF. Otherwise, the install stops for your to do it. TURF will also want the Codex that it uses for recordings installed, but the install deals with that.TURF is a Windows program, so I ran it in a virtual Win 7 session on my iMac. Given the environment, I kept the test simple. I ran TURF on top of a web based EHR and had it track my adding an antibiotic to a patient’s meds. TURF stayed out of the way, recording in the background.Here’s how TURF captured my session:Turf Playback ScreenThe left side screen played back my actions click for click. It let me run the screen at various speeds or stop it to add notes. The right screen lists each move’s attributes. You can mark any notable actions and document them for review by others. You can save your sessions for comparisons.

I found TURF to be a versatile, robust tool for EHR usability analysis. Its seeming complexity masks an ability to work in various settings and tackle hosts of problems.

If you aren’t happy with your EHR’s interface, TURF gives a remarkable tool to show what’s wrong and what you want. Indeed, with some adaptation you could use TURF to analyze almost any program’s usability. Not bad for a freebie.

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Does HIPAA Limit Emergency Communications?

David Sumner is not a name you’d normally see associated with EHRs, HIPAA or anything else to do with medical health technology. However, Sumner the CEO of the American Radio Relay League (ARRL) – the main US ham radio association – just made an important point that effects HIE, EHRs and medical health technology. Why did he venture into alien territory? He was concerned that HIPAA’s privacy requirements could severely limit hams emergency operations.

When it comes to emergencies, main communications systems often go down. Amateurs are often the only communications available. Whether it’s a hurricane, tornado, tsunami or earthquake these volunteers often react when others can’t. For example, hams have provided communications for the Boston Marathon for years. When the bombings occurred, cell systems were overwhelmed. They quickly switched from coordinating race operations to aiding relief efforts.

In an editorial in the October issue of QST, the ARRL’s magazine, Sumner noted that international agreements and federal law require amateur radio to communicate in the open and not use encryption. (Morse code, etc., are open standards and are not considered encryption.) Keeping things in the open is a guard against fraud and abuse. However, he wanted to know if this meant medically identifiable information, was an exception to the openness requirement?

In a word, no. To answer the question, he looked at HIPAA’s legislative history and the FCC’s opinion on transmitting patient information. Sumner found that HIPAA’s “regulations do not require encryption of radio transmissions of medical patient information.” (QST, October 2013, p. 9. It Seems to Us.

However, he goes on to say:

While HIPAA may not require encryption of radio transmissions, it is clear that medical care providers are very protective of patient privacy. Information identifying a patient is seldom transmitted anyway. Our served agencies may well prefer that the messages we send on their behalf not be intercepted by unknown listeners. If so there are steps, we can take such as using less-popular frequencies, directional antennas, minimum power and voice modes other than FM that will greatly reduce the likelihood of eavesdropping. (Ibid)

What this means for CIOs, emergency coordinators, etc., is that they need to discuss patient privacy, and amateur radio communications as part of their emergency planning.

[Disclosure: I hold Advanced Class amateur radio license, W3HBK, and am an ARRL member, but have no connection to Sumner or QST.]David Sumner is not a name you’d normally see associated with EHRs, HIPAA or anything else to do with medical health technology. However, Sumner the CEO of the American Radio Relay League (ARRL) – the main US ham radio association – just made an important point that effects HIE, EHRs and medical health technology. Why did he venture into alien territory? He was concerned that HIPAA’s privacy requirements could severely limit hams emergency operations.

When it comes to emergencies, main communications systems often go down. Amateurs are often the only communications available. Whether it’s a hurricane, tornado, tsunami or earthquake these volunteers often react when others can’t. For example, hams have provided communications for the Boston Marathon for years. When the bombings occurred, cell systems were overwhelmed. They quickly switched from coordinating race operations to aiding relief efforts.

In an editorial in the October issue of QST, the ARRL’s magazine, Sumner noted that international agreements and federal law require amateur radio to communicate in the open and not use encryption. (Morse code, etc., are open standards and are not considered encryption.) Keeping things in the open is a guard against fraud and abuse. However, he wanted to know if this meant medically identifiable information, was an exception to the openness requirement?

In a word, no. To answer the question, he looked at HIPAA’s legislative history and the FCC’s opinion on transmitting patient information. Sumner found that HIPAA’s “regulations do not require encryption of radio transmissions of medical patient information.” (QST, October 2013, p. 9. It Seems to Us.

However, he goes on to say:

While HIPAA may not require encryption of radio transmissions, it is clear that medical care providers are very protective of patient privacy. Information identifying a patient is seldom transmitted anyway. Our served agencies may well prefer that the messages we send on their behalf not be intercepted by unknown listeners. If so there are steps, we can take such as using less-popular frequencies, directional antennas, minimum power and voice modes other than FM that will greatly reduce the likelihood of eavesdropping. (Ibid)

What this means for CIOs, emergency coordinators, etc., is that they need to discuss patient privacy, and amateur radio communications as part of their emergency planning.

[Disclosure: I hold Advanced Class amateur radio license, W3HBK, and am an ARRL member, but have no connection to Sumner or QST.]

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The patient note is the biggest problem in medicine today.

[Note: These two posts are reprinted, with permission, from Dr. Robert M. Centor’s db’s Medical Rants]

The patient note is the biggest problem in medicine today

by RCENTOR on AUGUST 30, 2013

I spent yesterday at Hennepin County Hospital in Minneapolis. During lunch, we had a discussion about the thought process of internal medicine, and how we should teach thinking. Not surprisingly, attention turned to the patient note. The teachers in the audience bemoaned the degradation of the patient note.

We need a mission. We need to resuscitate the patient note. We need meaningful, readable, informative patient notes.

A previous rant recently ran on KevinMD – We need to reassess the patient note.

One comment challenged me as an ACP leader to have the organization address this issue.

Without revealing too much, let me assure readers that ACP has made administrative burdens the key policy issue this year.

Our notes have degenerated to satisfy billing requirements. Our EHRs are written primarily to satisfy billing requirements.

We need clinicians (that term used rather than physicians, because not all physicians do enough clinical work to be clinicians) to state the standards for good patient notes. We need real analyses and plans that every other physician can interpret and understand.

We do not need daily physical exams, except for the relevant systems. We do not need daily review of systems, rather just an updated history of the active problems and the answer to the open ended question about new complaints.

We should reclaim the patient note. I would prefer that we return to Larry Weed’s original SOAP notes. Each problem had a subjective, an objective, an assessment and a plan. As I wrote those notes, the pieces congealed into a larger whole. We should unite to object against notes designed for billing. And we should probably outlaw cut and paste.

The movement to improve patient notes

by RCENTOR on SEPTEMBER 3, 2013

Last week I tweeted about my recent posts on the patient note. This week I will continue trying to stimulate a movement and have bloggers and tweeters join that movement.

My friend and former Chair of ACP’s Board of Regents, Yul Ejnes, wrote a wonderful piece recently – English is the second language of medical documentation.

It is time for an “English First” movement for medical documentation. Call it “Leave No Narrative Behind” or something equally catchy. Let’s defend the medical record from the compliance officers, insurance companies, lawyers, regulators, accreditors, and EHR vendors. Let’s exile the “ten-point review of systems” to the auto repair shop!

That’s why the American College of Physicians recently approved a resolution that “endorses and actively promotes documentation within the electronic medical record (EMR) to improve communication that emphasizes the thought process underlying decision making, patient complexity, and medical necessity with clarity and without requiring repetition of past notes, tests and extraneous data.”

One of the most liberating things that I’ve done in a while is to use voice recognition software with my EHR. Instead of clicking boxes to generate a “Med Lib” supplemented by hastily typed short phrases, I now dictate a paragraph or two for the HPI, the review of systems, and the examination, and I document as thorough an assessment and plan as I did in the days that we documented in English. Someone can read my notes and know what I did, and more importantly, what I was thinking. That still doesn’t cure the systemic illness of billing needs trumping clinical needs in medical documentation. But it’s a start.

Yul has helped start the movement. Will you please blog and tweet about this movement?  We have many physicians involved in social media. If social media has power, we should use that power. Or do you like the notes that you find in charts and referral letters?

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Is That EHR Poll Worth The PDF It’s Printed On?

Note: This was also a guest publication on emrthoughts.com.

One thing that’s certain in the EHR world, someone is either polling or blogging about the results. The problem is how do you know which poll to believe and which to trash? It’s not an easy question, if for no other reason than the remarkable volume of studies.

Five Questions

To figure this out, I ask myself five questions about EHR polls. The answers help me figure out which are the real deal and which to ignore. Here my five:

  1. What does it say? What is its take away? Not just the headline, but what do the findings reveal? A study may be rigorously done, but if the author makes an inductive leap over a cliff from results to meaning, the work is for naught.
  2. Who’d they ask? A valid poll’s sample should be a microcosm of the whole group. The idea is that if you contacted everyone in the group you’d get the same results you got from your poll.
    If the survey lets anyone answer, then it only represents those who answered. For example, let’s say in 2012 Fox News and MSNBC each ran an on line poll of Romney versus Obama. The polls let anyone vote. Would you be surprised that Romney won on Fox, but Obama won on MSNBC?
  3. What did they ask? If I can read the questions, I look to see if they are fairly worded. I’m leery if they’re a version of the classic leading question, “How long have you been beating your wife?”
  4. Is it free? I can understand paying for a study that’s cost a lot to produce. What I can’t understand is a study that touts its findings, but puts its methodology behind a pay wall.
  5. Who did it? If you have questions, you should be able to contact the chief investigator.

Two EHR Poll Examples

Here are two recent studies that make important statements about the EHR field. Let’s see how they fare:

1. Accenture Survey Reveals Most US Doctors Believe Patients Should Help Update Their Electronic Health Records, But Shouldn’t Have Access to Their Full Record. URL: http://goo.gl/2ymctw.
a. The Claim. This poll makes a strong statement about how US doctors view patient’s role in their medical record. It says an overwhelming number of physicians, 82 percent, want their patients to update their EHRs, but only 31 percent believe that patients should be able to see their full record. If true, this has major policy implications.
b. Who Was Asked? Accenture hired Harris Interactive to administer the poll. Harris asked 3,700 physicians in eight countries. This included 500 US doctors. The poll was done on line. Any physician could participate.
The poll’s biggest problem is that it is a self selecting sample. There is no attempt to show that it is representative of US doctors as a whole, much less ambulatory, in patient, etc.
c. Questions? The questions asked aren’t listed.
d. Free? There is no charge for the viewing the poll. The results are posted in two .pdf pages on Accenuture’s site.
e. Investigator. No contact’s given for Harris Interactive. It lists three major Accenture officials.

2. Software Advice: Four Years Later: The Impact of the HITECH Act on EHR Implementations. URL:http://goo.gl/OcIeVO.
a. The Claim. Software Advice is an online technology service for those shopping for vertical software products. Their survey has these major findings:
i. Replacements. 31.2 percent of EHR shoppers were looking for a replacement. It was 21.0 percent in 2010.
ii. New. 16.4 percent of shoppers in 2013 were opening a new practice versus 12.2 in 2010.
iii. Paper. 50.9 percent were dropping paper systems compared to 64.9 percent in 2010.
b. Who Was Asked? Software Advice (SA) polled 385 practices chosen at random from those who had contacted the firm. They were chosen from a group of likely buyers who had contacted the firm. SA is clear about who was in their full group and who they sampled. They say:
i. Self-Selection Bias. Almost all of the individuals we qualified discovered our site through an Internet search and then consented to a 15-minute phone call discussing their EHR selection process. This may skew the results toward buyers who are more technologically savvy, as well as to those who are uncertain as to which product they are going to buy. Buyers who rely exclusively on referrals from colleagues to make their EHR purchase decisions, for example, were not likely to have been sampled. . . . [It also states:]Not included in this survey sample are the countless successful EHR implementations: buyers who purchased an EHR and absolutely love it; or practices for whom the savings in time and efficiency were well worth the costs of the software and the transition.
c. Questions? The questions are not available.
d. Free. Yes. The results are posted on its web site.
e. Investigator? There are no contacts for the survey, however SA’S Larik Malish answered comments from readers.

Of these two examples, Accenture’s claims are based on a self selecting survey, which is unlikely to represent more than those who answered. I wouldn’t give its claims much weight.

SA’s study is representative within its defined limits. Within those limits, it’s worth taking into account.

Trying to make sense of EHR poll claims is not for the meek. There are polls and then there are polls. A few questions can help sort them out.

Carl Bergman
Managing Partner
EHRSelector.com

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ONC Adds Guide on Contract Terms

The Office of National Coordinator has released a guide to common contract terms used in EHR agreements. It’s not just boilerplate; rather it has both candid and pointed advice to prospective buyers.

This is a good step forward. Anyone thinking of signing a contract with an EHR vendor would be well advised to read the guide. For example, its Warranty section says:

Given the importance of this issue, the EHR technology developer’s express commitment to remain certified in a timely manner should be an important consideration in selecting an EHR technology developer. If you proceed with an EHR technology developer that is unwilling to make this commitment, you may want to negotiate the ability to terminate the agreement without further payment if future certification is not met so you are able to transition to another EHR system without having to pay two EHR technology developers. The termination and wind down language discussed later will also be very important. (p. 11)

Need for Change. There has been a need for clarity in contract terms for a long time. That’s why we have the Contract Features/Implementation section in the Selector. However, this is a piecemeal approach to the issue. Currently, each vendor drafts an agreement and the buyer has to go over it asking for clarifications and changes. As a result, every contract is different. It’s not an easy process. I’ve often spent as much time negotiating an agreement as I did selecting the system. It doesn’t have to be that way.

If you hire an architect, it’s a different process. The American Institute of Architects has created a series of standard contract provisions that apply to its members. While not perfect, it certainly is a far more structured and developed approach than the EHR industry’s one at a time approach. This is not just a consumer side issue. EHR vendors spend a lot of time and expense on these agreements that could be better spent on service and support. The Electronics Health Record Association should pay a visit to the AIA.

EULAS. The guide applies to contracts for systems regardless of the way in which the EHR is delivered, that is on the web or not. As a practical matter on a web based system, you get its EULA (End User License Agreement) take it or leave it. If you reject it, you have no real option, but to look somewhere else. Here again, vendors need would do well to reconsider how they operate.

When we took the Selector back last year, one of the things we did was to review our EULA. We rewrote it to make it shorter, less obtuse and to spell out how we treat your information, etc. If you’d like a copy, email me at: carl@ehrselector.com

 

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New Features: Blue Button and QuickBooks

We’ve added three new features to the Selector:

Contract Features, etc.

  • CF46: Vendor subscribes to Electronic Health Record Association’s EHR Developer’s Code of Conduct.

The Electronic Health Association has adopted a code of conduct for its members. This feature shows if an EHR vendor subscribes to the code. See: himssehra.org/ASP/codeofconduct.asp

Practice Management Systems, etc.

  • PM49: Practice Management or EHR system is integrated with QuickBooks.

While many PMs or EHRs collect accounts receivable data, they don’t pass it on to the practice’s accounting system. In this case, we ask if there is a link to the most widely used small business accounting system, QuickBooks. This new feature can help users to understand if the proposed EHR, etc., will need to be interfaced to QB or if that function is built in.

Patient Portal Functionality

  • PP19: Supports Blue Button for patients to download their medical records.

Originated by the Veterans Administration, Blue Button is a service that lets a user download their medical record. This simplifies the process of providing this information and puts it in a standard text format for patient use and bringing in to other systems. This function is represented by this logo:

BlueButton

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EHRSelector.com’s Blog

Hi,
Our blog has several purposes. First it’s the place to fine out what changes and improvements we’ve made in the Selector, what’s planned and to find out what our users would like to see.

The blog also is a place for us to comment on the ever changing EHR field, what we consider to be best practices. In some instances it will include posts that have appeared in a few other places, for example, ehrandhippa.com.

Carl Bergman
Managing Partner
carl@ehrselector.com

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