The EHR 'killer app'

[Bari Shein]

While providers scramble to roll out EHR systems in time for ARRA funding, physicians have declared war on the clunky, proprietary software they are required to use. It complicates work flows, requires unnecessary data entry, and wastes time with superfluous windows and buttons, requiring the use of a maddening series of drop-down menus, mouse clicks, and work-arounds to perform even the simplest tasks. Today's EHR systems are sorely in need of the 'killer app', a term familiar to all professional computer programmers and software designers.

Short for "killer application", the term was coined as nerd-jargon to describe software so well-designed, so necessary and important, that it sets the universal standard for its niche. Examples would be Microsoft Office, Adobe Acrobat, Apple's iTunes, and Google Maps. In the online sphere, the title could be claimed by the likes of Amazon, Facebook, and Twitter.

So where is the EHR 'killer app'? Unfortunately, it doesn't yet exist, and instead providers find themselves courted by innumerous EHR vendors, each offering their own, proprietary methods for accomplishing familiar tasks. If providers aren't careful, they might find themselves locked into vendor-specific software systems and siloed IT universes.

Some providers are growing wiser, demanding more flexibility in selecting hospital software systems. CCHIT has recently expanded its certification criteria to include module-based alternatives, whereby a physician could integrate different modules from different vendors, each certified for a different function (e-prescribing, lab results, charting, data exchange). This model has proved fruitful for iPhone users, with the best apps quickly rising to the top of the "most downloaded" list.

So why are hospitals implementing clunky, unproved systems that cost millions of dollars, drastically alter familiar processes, and contribute to the unsettling trend of deinstallation? Perhaps those designing the software are not necessarily the ones most familiar with the day-to-day needs of physicians. Providers are also rushing to implement something, anything, in time to qualify for ARRA funds and avoid harsh penalties.

As EHR software becomes more wide spread, hopefully an evolutionary "survival of the fittest" will kill off the real clunkers, and the best EHR systems will rise to the top of the "most installed" list.

Over and over again we hear that for an EHR to be successful it must have full buy-in from hospital staff. Providers should be careful, and do their research on what others are using, all the while holding their breath until blue in the face, awaiting the EHR 'killer app'.

[CC-Conrad Clyburn-MedForeSight]

Comment from Dan Blum,

Actually CC this was a good reminder to be deliberate and actually to
go slow. I suspect that the CCHIT criteria will change and there will
likelly be other credentially authorities. dan

[Gerry Higgins]

Microsoft Word is a "killer app"? I think it was more about huge coporate investment and market dominance.

As for "killer apps", GenBank was not designed by committee, credentialing organizations and without so-called experts haggling about standards, and it has been one of the most commonly used bioinformatics software tools for decades.

And the "killer app" for EHRs? It's called Microsoft's data-driven Amalga UIS, originally developed as the 'Azyxxi' EHR here at Washington Hospital Center (MedStar Health).

[Greg]

Hmmm....'huge corporate investment and market dominance'? Is that MS's plan for Amalga?

[Rebecca Caroe]

Any new technology area takes time to build up. Early 'stars' are taken over by later arrivals with improved functionality.
Look at CRM. I was there at the beginning with Don Peppers and Martha Rogers doing "1to1" marketing. The second wave of technologies were significantly better than the first. Salesforce dominates the software as a service toolset now which didn't exist when it started. And Siebel has been sold to Oracle who missed the boat early on.

Looking forward to the opportunity an EHR offers to patients and the power it could confer to patient lobbying groups, I wrote a post on Thinking Pharma.
http://www.thinkingpharma.com/2009/07/the-possibility-of-the-portab...
Care to comment on my vision?

[Greg]

How about high-quality, user friendly voice recognition as a means of CPOE?

[Tracy Rausch]

I agree completely there needs to be a "killer app" but this isn't going to happen until EMR/health IT systems designers start to focus on how the EMR is used. Sure EMR's are going to improve administation and billing efficiency but at what cost? The cost comes at the point of care. Designers of EMR's need to first acknowledge that EMR's are more frequently used by nursing staff and not physicians. There is a vasty difference in EMR use from outpatient to inpatient, speciality clinical to OR, to ICU.

I learned long ago that no one is buying the line "we are making your life easier" as you increase their workload. If you install a system and it requires the clinican to do 8 more steps than it did before, it isn't going to happen. There sole job is not data entry it is taking care of the patient. Until you fix the issues with health IT at the point of care there is going to be push back. As being an installer of such equipment (on clinical side) for many years it just doens't fit. The systems have to be intelligent and interactive. Data must be visualized in a way that you can figure out what it says in seconds not minutes, and they have to be easy to use!

[John A. Liebert, MD]

From my experience in working within multiple clinical sites and with, by necessity, nearly all current major vendors' EMRs + US Army EHR, AHLTA, I think that this chain of inquiry is most valuable. I was so often challenged and provoked by hospital management's testimonials to "Lean Management" that I spent days researching a term and process totally foreign to me. I'm glad, however, I did, because I studied the book, The Toyota Way; Lean Management and Lean Engineering are synonymous with The Toyota Way. I could find no medical system, including those claiming to be "lean managed", in fact qualifying to invoke such testimonial for their operation. The King County Medical Society (Seattle) Bulletin published my article, "Unity in Healthcare The Toyota Way: Can Lean Engineering Fix North American Health Care?".
Here is one salient quote from it, . David Burnett, M.D., Vice-President and Director of The Clinical Practice Advancement Center, University Health System Consortium, Oak Brook, Ill., describes the operation of a successful health care network as the logistical equivalent of Operation Desert Storm.
“For each network, there are thousands of doctors and tens of hospitals and other providers; for each hospital and other provider, there are ten to a thousand contracts; for each physician, there are 10 to 100 contracts and 1,000 to 2,000 patients; for each physician contract, there are different payment levels and methods and differing levels of risk; for each plan there are different authorization and reporting requirements; and so on, Given this level of complexity, it’s no wonder that a key goal of network management is “alignment”: get everyone to agree on common goals, set objectives that have everyone pulling in the same direction, and design strategies that encourage everyone to cooperate”. (4)
EMRs and EHRs, with few exceptions, are imposed upon most constituent users, whether doctors, nurses, pharmacists, security, imaging, lab etc. When millions of dollars are tied up in the initial purchase of such systems, necessitating more millions annually for training, maintenance and upgrades, why can't it be done right from the start? Is it that hard to get respected representatives from mediccal specialty and other clinical disciplinary staffs- i.e. ER docs, hospitalists, Psychiatrists; a Pharmacist; a Clinical Pathologist; Medical Records!!!; representative deparmental nurses etc to sit at the table and discuss their wishes, needs and barriers for usage of a system? It has been commented upon before, that vendors are aware that their own staff, including MDs, don't understand the clinical comlexity of computerized needs and solutions within hospitals and clinics. So, why don't they find out? Is it simply easier to sell the IT Director the package, wait till the ink dries and then tough it out. Everyone will come around - or, they can simply leave. What is the difference between such implementation of a networked solution, marketing & sales strategy and power grab by one internal constituency or another? And, then to call this Lean Managed, when no Unity was ever intended from the beginning is quite a travesty, which occurs all the time. John Liebert