How to Revive a Failed EHR Implementation

My latest post on  Here’s an idea I think merits consideration.

What do you think?

Microsoft EMR: It’s Not Just a Matter of When, It’s a Matter of Who

This guest post ties nicely to some of what I have been writing about regarding why I think firms like Apple, Microsoft, and Google will be the real N-HIN, why PHRs will become EMRs on super smart next gen devices.

Its author is Austin Merritt of, a web site that provides advice on selecting EHR software.  I think the strategic reason for Microsoft’s entry into EMR would not be because there are big bucks to be made from a limited number of physicians but because it gives them a foothold into two of the key stakeholders; doctors and patients, one via an EMR and the other through its PHR.  If that is where they intend to stop, they’ve wasted everyone’s time.  I think they have bigger plans, and those plans include having patients walk in to the doctor’s office, both having the same EMR on the same or compatible devices.  The rest of this post is Austin’s.

Microsoft Dynamics is largely present in just about every software market but medical. And they’re missing out big time. The United States healthcare IT market is growing at about 13% per year and is expected to reach $35 billion in 20111. The biggest opportunity for growth in the industry is among ambulatory care physician practices, partly due to the Stimulus Bill requiring the use of electronic health records (EHR) systems by 2015.

You would think Microsoft would be in such a promising industry, but you won’t find a Microsoft EHR available. The primary reason why is that EHRs are highly specialized, and Microsoft’s main products (Dynamics, CRM, and SharePoint) don’t come anywhere near the needs of physician practices. It would be very difficult for Microsoft to build an EHR from scratch and introduce it to the market. So what should Microsoft do to enter the industry? Acquire a current player.

Such an entry into the medical market would mimic the acquisition spree that Microsoft conducted between 2000 and 2002, when it acquired Great PlainsNavision, Damgaard, and several related vendors. These systems were re-branded and offered as Microsoft Dynamics. Before these acquisitions, Microsoft was not present in the enterprise resource planning (ERP) application market. Its only ERP presence was as an infrastructure vendor, licensing SQL Server databases and related platforms to support application rollouts. However, this lack of application presence gave competitors such as Oracle and SAP the opportunity to squeeze Microsoft out of the ERP infrastructure market by pushing Unix, Oracle databases and IBM DB2. By acquiring several applications, Microsoft was able to drive sales of its SQL Server and Windows Servers directly, in addition to the Dynamics applications themselves. This strategy proved effective in giving Microsoft a multi-billion dollar share of the lucrative ERP market.

Setting its sights on the medical market, Microsoft is starting to squeeze its way in with a few smaller acquisitions and developments of its own, mainly Amalga and HealthVault. However, these current medical offerings are on the periphery of the market and do not really target the sweet spot: electronic health records for physician practices. An intelligent acquisition of a large EHR player would provide a key piece of the puzzle for Microsoft’s entry into the medical market.

Acquired by Microsoft in 2006, Amalga provides information connectivity and interoperability to large healthcare networks. It is the primary Microsoft healthcare offering in the industry at this point, although it is not available in the United States. Microsoft may be planning to offer it domestically, as it did with Navision Damgaard, or may be looking to acquire a domestic vendor to complement it. Regardless of Microsoft’s strategy, Amalga still would not address the physician practice EHR market.

On the other end of the spectrum, HealthVault is a patient-managed, centralized health records solution. It is essentially designed to be a reference point for consumers, not a substitute for medical records. If Microsoft were able to introduce an EHR to the market and enable its users to make records accessible to patients, labs, specialists and pharmacies via HealthVault, then they would really be on to something. This synergy with its other products would just be an added bonus to having its own EHR.

So what would Microsoft prioritize as its key acquisition criteria when evaluating EHR targets? They would certainly want target vendors who possess the following:

  1. Large market share and name brand recognition. Microsoft usually likes to be the largest name in the business, so they would definitely want to sell a “big-name” system with which most buyers are already familiar.
  2. A scalable product for small and large practices. Microsoft would need to be able to cover a wide range of medical customers. While its bread and butter is always in the small and mid-size market, they would want scalability into the largest organizations.
  3. A .Net architecture to drag along infrastructure sales. Reinforcing the position of .Net in the medical software marketplace would be important because it would drive further sales of Microsoft infrastructure while squeezing out Unix, Oracle and IBM.
  4. An established, indirect sales channel. Microsoft historically favors selling through partners, including the existing Dynamics dealer network. An EHR vendor with a large dealer network would provide Microsoft an easily transferable sales channel and process.

So which EHR vendor should Microsoft acquire? This is where it starts to get interesting. We decided to examine Microsoft’s ten most logical targets in detail. Two very popular products, GE Healthcare’s Centricity and McKesson’s Practice Partner, did not make the top ten list. While these systems meet many criteria, the parent companies – General Electric and McKesson – are not really acquirable by Microsoft. The remaining ten are outlined below.

  • NextGen – One of the “biggest names” in EHRs, NextGen focuses on medium to large enterprises. However, its system is certainly able to scale down to smaller practices. While it is often too expensive for groups with less than ten physicians, it has a strong position in the sweet spot of the market. Its .Net-based system is sold both directly and through a channel network, so NextGen is a good fit for Microsoft.
  • GreenWay – GreenWay has a nice product, but is toward the smaller end of the companies on this list. It sells primarily directly and has some channel partners. PrimeSuite 2008, its EHR and practice management sytem, is .Net-based and is popular among small and mid-sized groups. Microsoft could leverage its resources and Greenway’s technology to become a major force in the industry. Moreover, Greenway doesn’t come with any legacy of old architecture or acquired customers.
  • Pulse – Pulse has quickly climbed its way into the ranks of bigger EHR vendors and will likely stay here for some time. They were one of the first vendors to achieve 2011 CCHIT certification and are receiving a lot of buzz as a result. While the system is scalable and .Net based, Microsoft would likely want to pursue bigger fish for now.
  • Aprima – Aprima (formerly known as iMedica) has focused on its .Net framework and N-tier architecture from the beginning. As a result, its modern platform and interface make it widely received among physicians across a broad range of specialties. While Microsoft would likely focus on larger companies first, Aprima could be a nice additional partner to champion .Net.
  • AllScripts/Misys – A large brand and a publicly-traded company, it is a logical first place to look. After all, the company claims to have 160,000 physicians using its products. However, the 2008 merger between AllScripts and Misys presents the usual integration challenge, which might keep this firm busy for quite a while. Although we think the future of AllScripts/Misys is very promising, Microsoft probably wouldn’t get involved at this point.
  • eClinicalWorks – This system is probably the most ubiquitous of the list, especially among smaller practices. The recent deal to sell eClinicalWorks through WalMart will definitely increase its brand recognition and share of the market. However, the system is built in Java, an open programming language that is the traditional enterprise alternative to Microsoft .Net. Microsoft would most likely rather acquire a pure .Net system or one that is at least close to it, especially with Oracle, IBM and SAP all embracing Java.
  • Eclipsys – Eclipsys acquired MediNotes in 2009 in an attempt to move users to its Peak Practice EHR. While Eclipsys is fairly popular among hospitals, Peak Practice has not achieved similar success among small to mid-size outpatient practices. Existing MediNotes users are not thrilled about being forced to purchase Peak Practice and we’ve seen quite a few seeking a new solution from a new vendor. We think the success of the MediNotes deal is unclear and Microsoft would steer clear for now.
  • Athena – The youngest company on this list, Athena’s product offering is slightly different from the others. Its system is offered via software as a service (SaaS) and is combined with outsourced billing and revenue cycle management services. This offering is indeed unique, but not a suitable target for Microsoft due to its SaaS offering and labor-intensive service component.
  • Epic – This company possesses an interesting niche in the market. It has only 190 clients, but 150,000 physicians using its products. This is due to its focus on only the largest healthcare organizations in the United States. While this focus is great for Epic, it wouldn’t be effective for Microsoft. Epic will never be able to achieve the ubiquity in the small to mid-sized market where Microsoft dominates. It also sells direct, contrary to Microsoft’s traditional indirect sales mode.
  • Cerner – Cerner’s cash cow is Millenium, a product designed primarily for hospitals. PowerWorks, its outpatient EHR, does not possess the market share among physician practices that Millenium enjoys among hospitals. While Cerner is a recognized name, few practices consider PowerWorks. It is also an older system. Cerner would need to improve its PowerWorks offering before becoming a suitable target for Microsoft.

Although NextGen is not currently dominant amongst small practices, Microsoft could bring them downmarket. NextGen is unable to serve these smaller buyers for two reasons: 1) small practices cannot afford an enterprise expenditure; and, 2) NextGen does not want to (and maybe cannot) devote resources to chasing smaller deals. If Microsoft owned NextGen, they could double down on pursuing smaller practices, perhaps through their channel partners. They may even lower prices to buy market share and make up the difference with revenue from services, SQL licenses, and maintenance.

Which EHR do you think Microsoft should acquire?

Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: WordPressLinkedInTwitterMeetupBlog RSS

What if our EMRs were portable?

I am wondering how much of the cost of a hospital’s EHR system includes building in the functionality of individuals’ EMRs and making them transportable.

What if EMR’s were made portable and they could be carried around by patients on super smart devices?

Any thoughts?

saint       Paul M. Roemer
       Chief Imaginist, Healthcare IT Strategy
       1475 Luna Drive, Downingtown, PA 19335
       +1 (484) 885-6942 

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

The change keeps changing

Hello to those whom I’ve yet to meet.  This is rather long, so you may wish to grab a sandwich.

I write to share a few thoughts.  I reside in the small place where those who refuse to drink the Kool Aid reside. For those who haven’t been there, it’s where those who place principle over fees dare to tread.

Where to begin? How to build your provider executive team? (Those who wish to throw cabbages should move closer to their laptops so as not to be denied a decent launching point.)

I comment on behalf of those in the majority who have either not started or hopefully have not reached the EHR points of no return—those are points at which you realize that without a major infusion of dollars and additional time your project will not succeed. Those who have completed their implementation, I dare say for many no amount of team building will help. Without being intentionally Clintonian—well, maybe a little—I guess it depends on what your definition of completed is.

If I were staffing a healthcare organization, to be of the most value to the hospital, I’d staff to overcome whatever is lying in wait on the horizon, external influences—the implications of reform and Stages 2 and 3 of Meaningful Use, and a national roll out of EHR with no viable plan to get there.  Staffing only to execute today’s perceived demands will get people shot and will fail to meet the needs of hospital. To succeed we need to exercise an understanding of what is about to happen to healthcare and to build a staff to meet those implications.

Several CEOs have shared that they are at a total loss when it comes to understanding the healthcare implications of reform and IT.  They’ve also indicated—don’t yell at me for this—they don’t think their IT executives understand the business issues surrounding EHR and reform.  I somewhat disagree with that perspective.

Here’s a simplified version of the targets I think most of today’s hospital CIOs are trying to hit.

1. Certification
2. Meaningful use
3. Interoperability—perhaps
4. Budget
5. Timing
6. Vendor management
7. Training
8. User acceptance
9. Change management
10. Work flow improvement
11. Managing upwards

There are plenty of facts that could allow one to conclude that these targets have a Gossamer quality to them.  Here’s what I think. You don’t have to accept this, and you can argue this from a technology viewpoint—and you will win the argument. I recently started to raise the following ideas, and they seem to be finding purchase—I like that word, and since this is my piece, I used it.

Before we go there, may I share my reasoning? From a business perspective, many would say the business of healthcare must move from a 0.2 to a 2.0 business model. (This is not the same as the healthcare business—the clinical side.)  The carrot?  The ARRA incentives—an amount that for many providers will prove to be more of a rounding error than a substantive rebate.

Large healthcare providers are being asked to hit complex, undefined, and moving targets, and they are planning on adapting to reform and reforming their own business model while they implement systems which will change how everyone works.  Hospitals are making eight and nine figure purchase decisions based in part on solving business problems they have not articulated. If success is measured as being on-time, in-budget, and fully functional and accepted, for any project in excess of $10,000,000, the chances of failure are far greater than the chances of success.

Their overriding business driver seems to be that the government told them to do this. Providers are making purchasing decisions without defining their requirements. Some will spend more on an EHR system than they would to build a new hospital wing.  Many don’t know what the EHR should cost, yet they have a budget. Many don’t know if they need a blue one or a green one, if it comes in a box, or if they need to water it.

So, where would I staff to help ensure my success—this is sort of like Dr. Seuss’, “If I ran the Circus”—the one with Sneelock in the old vacant lot.  I’d staff with a heavy emphasis on the following subject matter experts:

• Planning & Innovation
• Flexibility
• Change Management
• PR & Marketing

Contrary to popular belief, not all of these high-level people need to have great understanding of healthcare or IT. You probably already have enough medical and IT expertise to last a lifetime.

Here’s why I think this is important. Here’s what I believe will happen. Three to five years for now the government would like us to believe there will be a network of articulated EHRs with different standards, comprised of hundreds of vendor products, connected to hundred of RHIOs, and mapped to a N-HIN.  Under the proposed model, standardization will not occur if only for the fact that there is no monetary value to those vendors whose standards are not standard.

Interoperability, cost, and the lack of standardization will force a different solution—one which is portable.  I think the solution will have to be something along the lines of a single, national, open, browser-based EHR.  It will be driven by consumers.  Consumers will purchase the next generation of super-smart portable devices that offer a combination of iPad/iPhone functionality.

The Personal Health (PRH) will have evolved to become the EMR.  How is this possible?  What do smart devices do?  They do one thing, billions of times each day, and they do it perfectly—they send and receive ones and zeros.  That is what today’s EMR are—ones and zeroes.  Those next-gen devices will be EMR-capable.  Why?  Because there are more than a hundred million customers who will keep buying these devices.

The so-called N-HIN will be the new Super Internet—not some cobbled together network of RHIOs.

Firms like Apple, Google, and Microsoft will drive this change.  We already buy everything they offer, in fact, we line up at midnight to do so.  By then, those firms will care less about selling the devices than they will about transporting the ones and zeroes that comprise the data.  Their current PHRs are their way of introducing themselves to consumers as players in healthcare.

The point I am trying to drive home is that from being able to adapt to change and reform, lean towards staffing the unknown.  Staff with leaders, innovators, and people who can turn on a dime. Build your organization like turning on a dime is your number one requirement. Don’t waste time and money worrying about Certification or Meaningful Use. If anyone asks you why, you can blame me.

If you want a real reason, I have two. First, they won’t mean a thing five years from now. Second, if I am the person writing an incentive check, I want to know one and only one thing—will your system connect with the other system for which I am also writing a check?  That is the government’s home run.

saint Paul M. Roemer
Chief Imaginist, Healthcare IT Strategy

1475 Luna Drive, Downingtown, PA 19335
+1 (484) 885-6942

My profiles: LinkedInWordPressTwitterMeetupBlog RSS
Contact me: Google Talk/paulroemer Skype/paulroemer Google Wave/paulroemer

How to improve EMR adoption-a guest blog

The well-written guest blog which follows is by Richard Hom, Public Policy Consultant, Richard Hom Consulting.  You can also find him on Twitter at grandrounds4ods.  Thanks Richard for contributing.

Medical providers across the country are grappling with many medical care issues. Of the many, one that has received much attention, thought and talk has been computerized electronic medical records (EMR).  Although not a novel idea, EMR use and adoption have regained center stage as economic stimulus funding from the Federal Government has been dangled as an added incentive.

The monetary incentive, though, has not overcome the resistance and hesitation that providers have toward EMRs.  More urgent problems that preclude EMR adoption dwindling reimbursement, rising malpractice premiums and an array of private and public regulatory issues that smother provider authority.  In this atmosphere of medical practice the promise of the benefits of EMR adoption has not outweighed the attention gained by the aforementioned issues.

If EMR adoption is to spread and embraced by the medical community, more tangible and direct benefits may be needed. For example, with EMR use, physician accountability is enhanced by legible and available documentation of patient care. Tying EMR use to malpractice premiums would be an attractive carrot, just as a non-smoker might benefit with health or automobile insurance.

Likewise, EMR use should benefit a physician’s patients by easing information sharing.  Therefore, an initiative to lessen the burden of eligibility of benefits or referrals to specialists would be welcomed.

Finally, electronic presentation of Explanation of Medical Benefit forms (EOMBs), rejections and electronic resubmission should further invite greater EMR participation. In this one area alone, the blizzard of paper correspondence surrounding reimbursement is a significant problem area that may be lessened with EMRs and practice management software.

In summary, a cash incentive may attract medical providers, but only those providers who already may have successful office workflow processes and may require only a cash incentive. For the remaining, though, relief from the paper flow, claims submission,and  malpractice premiums may be the carrot that will move more providers to EMR adoption.

Health IT: magical thinking?

Below are a few thoughts I submitted to the WSJ Healthblog at


Interesting to note that they refer to the IT as it.  That’s because healthcare IT is being approached as a solution looking for a problem.  In may respects, the problem providers are trying to solve is the one created by Washington (the city, not the 1st president) mandating EHR.
If that’s the problem a provider is trying to solve, all solutions look good.  Healthcare providers need to approach HIT and EHR as real business problems, problems that require adult supervision, thoughtful analysis, and program officers with a track record of implementing big, hairy IT projects.
What’s your take on it?



A doctor writes about his EMR experience

162_6The following is a response I received to a discussion I raised on a LinkedIn group.  It’s written by Dr. Richard Lamson and is used with his permission.  I liked that it didn’t follow some of the EMR/EHR cheerleading that seems to dominate much of what’s written.

I wish I could say it was a learning “curve”, it’s just a “slope” with no asymptote in sight for many EMR products.

Well, no, I guess that’s not right. Your cardiologist will eventually get to 30/30 or so instead of 10/50, so there is an asymptote, it’s just not what it was with paper charts. Say what you will about paper charts (they’re unreliable, slow, get lost easily — all true), they’ve been refined by several generations of physicians, using technology that was well understood 200+ years ago. The data density of pen/ink on paper is very high, (think genograms, drawings of the location of lesions, etc.), the input bandwidth very high, and it is something with which we have been familiar since preschool scribbling with crayons (of course, some physicians’ charts would be improved by scribbling lessons!).

The EMR user interfaces out there are at most 10-12 years old, The input bandwidth is not very high — at most it is dictation speed but with a higher error rate. Because of copy/paste technology, a lot of “information” in charts is copied and pasted from previous notes and does not necessarily reflect what the physican did on this visit. Also, it might not be true this time. Does every doctor look at every diabetic’s feet at every visit? I try to, but when I’m 45 minutes behind sometimes I defer it to the next visit, especially when they can’t put their own shoes back on after I take them off. I try to edit out the foot exam

Don’t get me started on the warnings that EMRs give you every time you open a new patient, write a prescription, etc. You get warning fatigue and tend to blow past them without reading them after a while, since 99+% of them are not germane (oh, this patient’s taking aspirin, maybe they’ve had a heart attack in the last 10 minutes, better not write them for a migraine medication…). These warnings are basically lawsuits waiting to happen. I can hear the attorney now: “But, Doctor, your EMR warned you that this was a bad medication to use in this case, why did you write it anyway?” “Well, you see, it had given me that warning buried in among 20 other warnings, and it was probably the only warning all day that was useful, how can I read 400 warnings a day to see which one is useful?” Cha-ching!


Is EHR as difficult as everyone says it is?

Yes, and then some.  EHR is at the beginning of a national rollout .
• Studies suggest that 200,000 healthcare IT professionals are needed for EHR. The total number it healthcare IT professionals today is 100,000
• It’s not known which EHRs qualify for incentives under ARRA
• Less than 8% of non-VA hospitals have EHR in even a single department (this does not mean these pass meaningful use test)
• Only 1.5% have them in all departments
• Studies state that 1/3 to 2/3’s of implementations fail
• Implementation by small practices has been almost non-existent
• Small and individual practices will need a full service “wrap around” solution encompassing the following services:
o Project management
o Selection
o Implementation
o Adapting work flows
o Training
o Support
• Major reasons for not doing EHR are
o Up-front costs
o Lack of IT skills
o Ongoing support costs
• Hospitals and large providers usually use their own IT departments for EHR, none of which has ever implemented EHR. Hence for the most important project undertaken by a provider, they elect to do it with people with no experience, relying on the vendor
• Where will the EHR vendors find the IT expertise and project management resources to staff a national roll out?