The effort required to write blog posts on a regular (or even infrequent) basis has become too much for me to bear alone.  Therefore, I have asked valued partners of Amazing Charts to contribute posts about Health IT, Electronic Health Records, e-Prescribing, and other topics of interest.

Our first contributor is Mark Shary, CEO of Updox, a leader in provider and patient communications software.  I hope you find his blog post as poignantly true as I did.

- Jon Bertman

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In my childhood neighborhood in Indianapolis, we made frequent trips to Hedlund’s Hardware, welcomed by its creaky, warped wooden floor planks and musty aisles.  My dad swore there wasn’t a problem the family-run store couldn’t solve.  He sought advice from the shopkeepers on cars, appliances, mechanics, and other vendors, which they willingly offered, and he’d always make sure to buy something in return.

I didn’t want to lose Hedland’s, and I don’t want all of my healthcare to go the way of Lowes and Home Depot.  I want my primary healthcare to be as familiar and comfortable and trusting as those trips to the neighborhood hardware.  Fortunately, in my current neighborhood in Worthington, Ohio, we still have our local hardware, as we also do around the corner from our office in Dublin.  What allowed these shops to prosper in the face of the march to institutionalize hardware stores?

Capable, trustworthy service, reasonable supply and not unreasonable (but not the lowest) prices seem to be the core elements, but plenty of non-survivors shared these attributes, too.  Two major, related advances that each embraced gave them the foundation to compete well enough with the big chains that they were given a chance by their customers to let their unique brand of service to keep them in business.

First, they negotiated as a group (Ace, TruValue, etc.), much as independent physicians do today with payors and vendors.  Second, they adopted technology and tools that allowed them to be efficient and more importantly, allowed their customers to get the service they were expecting.  Tracking inventory accurately allowed them to stay stocked, rather than Hedlund’s telling dad, in an entirely reliable way, that they’d get the tool for him by next week.  Advertising and adjusting prices for certain commodities kept their volume high enough to sell their premium products.

Independent physicians will face similar challenges as institutional healthcare becomes more automated, where patients can more easily serve themselves and get information electronically that they historically relied on from a visit.  Customer conveniences, such as scheduling online and knowing costs in advance, will be baseline capabilities to retain patients, but just as importantly, will become needed efficiency gains, just to remain competitive.

Technology, and specifically software, might seem like cost that’s not core to the provision of medicine, but when it’s done well, it actually allows the providers’ unique capability and differentiated service to shine through.  As a patient, I want the physician’s total focus.  The energy I put into scheduling, waiting, paying my bill, getting reports and remembering advice is not why I like my primary doctor – it’s those few minutes I get to talk, exchange notes, and see the look of confidence.

Leveraging practical software, sharing best practices with it, and supporting one another and your key vendors is a key part of the ecosystem you have to have, if we will retain “our neighborhood physician”.  Technology is the great equalizer – use it well, so that the great differentiator in private practitioners can march on.

Small physician practices, clinics, hospitals and health networks spent the greater part of 2009 and 2010 trying to grasp  the “what and how” behind meeting these expectations and then moved either towards satisfying or resisting the federal mandate to integrate electronic medical record systems into their practices.

While some medical practitioners are encouraged to achieve meaningful use simply because they see EMRs as the best way to go about improving patient care and facilitating physician-patient interaction, the promise of stimulus funding – or fear of financial penalization if they do not abide by “meaningful use” health technology adoption – has served as a main driving factor for the majority of adopters.   And even the savviest practitioners have significant questions about which of the 300+ EHRs will be right for their business needs – what are some of the unseen costs? How much money is too much money for an EHR? How will the EHR integrate into my practice management?  Are there annual updates and renewal costs? Will I have to train new staff members?  The list goes on and on, but one question few have asked is – what happens if the Federal Government takes the incentive away?

The House’s Spending Reduction Act of 2011 (H.R. 408) shines a light on some substantial gaps surrounding EHR adoption that providers should take seriously.  The bill—introduced in January of this year—seeks to reduce federal spending by roughly $2.5 trillion by cutting financing for certain government programs. One cut may come in the form of “taking back” the $27 billion built into the federal budget for disbursement to healthcare providers leading the way in EHR adoption. This serious possibility was discussed in a recent article in Healthcare IT News.

The threats associated with a tough economic time for the country mean that stimulus funds are always in jeopardy, but for many hospital and health network administrators, news of the House bill comes after they’ve invested upwards of $35,000 for initial EHR purchases and nearly $1,500 per month for ongoing support. In addition to exorbitant costs for initial set up and maintenance with large EHR vendors, physicians and hospital administrators have to weather EHR certification processes with vendors which sometimes produce additional costs.

Amidst the stimulus debate, physicians and administrators are caught somewhere in the middle. They are understandably hesitant to continue to move toward electronic medical record system integration due to high cost and waning guarantee of financial reimbursement, but current legislation requires they achieve “meaningful use” of health information technology systems by 2014. How do they do the right thing?

It is important to keep in mind that EHRs were never intended to be the “silver bullet” in improving the quality of healthcare so whether managing a network of hospitals or a solo practice, making the decision to adopt electronic health record technology should be driven by the needs of the practice’s physicians.  EHRs help physicians better care for patients by organizing data, providing better access to the data and eventually connecting the data across health systems. The intention is to simplify the otherwise cumbersome processes to save time for health workers so that they can better focus on caring for patients.

The true test of a good EHR is if it is both affordable and usable.  In order to realize the benefits of EHRs, programs cannot be so complex and confusing that they actually require more time to navigate than paper charts or leave physicians with little time to actually use the information to the advantage of the practice and patients. Concurrently, programs should not be so costly that they severely limit the capacity of a hospital or clinic to make updates to systems or that they would successfully bankrupt a practice should federal incentives cease to exist. Ideally, a practice’s information technology decision-making team will choose solutions that support quality of care, facilitate record keeping and mobility and advance evidence-based medicine while maintaining scalability per the unique needs of the clinic or hospital.

Today, when the EHR industry is growing rapidly, healthcare executives are tasked with wading through the clutter to find a vendor that best suits the needs of the practice and physicians. While proponents of the ARRA/HITECH Act assert that the SRA bill will not likely pass, other barriers to effective EHR system integration continue exist.  So if you just want to do the right thing, select an EHR that fits your practice – and that is affordable and usable for you and your staff.

This may seem obvious, but you’d be amazed how many physicians spend hour after hour at the end of the day trying to recall the visit and stumble through multiple menus and windows trying to get the data into their EHR.  If you find that documenting with your EHR takes as long as the patient visit, you’ve experienced first-hand why the concept of EHR usability is now becoming a critical issue, and why some unhappy physicians are calling for EHR Lemon Laws.

This leads to Tip #2: codify only the data that needs to be codified. Though many EHRs, designed by programmers and database administrators, have decided that every bit of data deserves its own database field, this is not feasible given the volume of information generated during a visit. While medications, allergies, blood pressure, and other data needs its own place, being forced to check box after box to record “three days of dry cough,” makes little sense and ensures you’ll be spending more time doing your notes than you did when using paper charts.

Finally, Tip #3 is to be sure to harness the power of your staff when using your EHR.  Having staff enter demographics, document as much of the chief complaint and HPI as possible, and doing other tasks within the EHR can save you valuable time. Most EHRs have an integrated intra-office messaging function that can really boost office productivity, and encouraging your staff to use it for everything – including refill requests and confirming your lunch order – should be a priority.

Any tips you’d like to share with readers?

• Amazing Charts Electronic Health Record (EHR/EMR) License: $1995 per provider (one time charge, which now includes the first year of our Guardian Angel Support & Maintenance)
• Guardian Angel Support & Maintenance: $995/year per provider (includes maintenance, updates, support, and ePrescribing)

This new pricing goes is effective November 1, 2010, so I recommend all existing practices, and those in their trial period, purchase the correct number of provider licenses before that date.  We have enhanced our Pay Portal site to allow current customers to pre-purchase two years of Guardian Angel Support & Maintenance at the current price to thus “lock-in” the older price for the next 24 months.

Nobody likes to see prices go up, but we feel it is necessary to continue to advance our software and services to remain in line with the new government regulations relating to the ARRA/HITECH stimulus money and continue to add the features our users want in the time frame they need.

And just to keep it all in perspective,even at our proposed new price, Amazing Charts remains not only the highest rated EHR according to a number of independent EHR user surveys, but we are still – by far – the least expensive EHR – whether calculated for a solo or multi-provider practice and regardless of whether the other EHR was delivered as a full client/server system or leased as an ASP.

Our biggest assets (low cost and simple usability) are also our biggest difficulties (limited resources and figuring out how to make complex certification requirements easy to use). We must set difficult priorities and implement them in an order that sometimes changes based on government and third-party changes, and sometimes means we don’t get the perfect solution the first time around.

For example, we had to delay Practice Management to allow for CCHIT certification, Surescripts certification, and improved eRx. We have held the letter writer and making order tracking and immunization entry easier as we strive to ensure that we can support the PCMH and meaningful use requirements since money from these is imminent and delaying these means less money for the majority of our users.

Amazing Charts must be eligible for every extra penny that may be available to help supplement the lousy reimbursements that most physicians experience, even if this means some users will be frustrated with certain features they know could be done better. And while I understand that not everybody agrees with these priorities, they are the tough decisions we’ve had to make to ensure we will be around for years to come.

So let me outline our current priorities. Our goal is to get the new ONC certification for meaningful use done by the end of the year and PM complete within that time frame (or very soon thereafter). These are currently our top priorities based on many of our users opinions, as well as the reality that the money is only available for a period of time starting in 2011 and ending in 2016.

Getting the promised features done in a time-frame that is promised, and with minimal bugs, is also something you have demanded and is absolutely a reasonable expectation. To that end, we have hired a bunch of developers, added a QA department to minimize the risk of bugs in our releases, and painstakingly attacked annoyances found in prior versions. Version 5.1, for example, literally has over 200 fixed “bugs” and other issues in addition to the major features of improved electronic refills and Surescripts certification. But these priorities trumped fixing the letter writer and other items that may seem easy to solve, but actually “touch” a lot of other areas of the program and will be quite programmer-intensive.

We have also added many new Help desk folks, and the learning curve of training these folks and getting them up to speed with our product, services – and most importantly, our corporate culture of fairness, honesty, hard-work, and dedication to our clients – takes awhile. (We have also had to fire folks who just couldn’t get the standard corporate bureaucratic mindset out of their head.)

For those who have been with us the longest and witnessed our steady progression, I would hope you are confident we will get there and end up with it done right. It may sometimes be slower than you would like (it certainly is slower than I would like), and there may be some hiccups along the way, but we learn and adapt and step by step, Amazing Charts will continue to strive to provide the absolute best tool to help run your practice – and do so at a reasonable price.

The big picture of our upcoming releases are:

V5.1 (expected to be released to beta testing in the next week or so). This version has improved eRX refill ability (and is SureScripts certified), and should have our iPhone “Amazing Charts OnCall” app to allow after-hours documentation of patient phone calls.

V5.2 – expected to be released by years end, and expected to be ARRA/HITECH certified for MU as well as the ability to generate reports to allow incentive payments (this version may be renamed V6 depending on certification requirements).

V6 – expected to be released early in 2011 and contain our Practice Management ties for eligibility, direct clearinghouse connection, etc.

Click here to see some of the photos on our FaceBook page, including those from our 5K run (okay, actually it was a 0.5K walk to Ardeo Restaurant where we had a great time getting to know each other). Even the weather was perfect for Providence’s Waterfire, which was as beautiful and inspiring as ever.

I’d like to acknowledge the hard work and dedication of the many people who made ACUC possible.  First and foremost was the ACUC Advisory Committee, namely Bert Adams, Jim Blaine, Martin Sechrist, and Wendell Wheeler.  Without their uncompensated time and effort, the conference would not have taken place.

Also, I have to thank the employees of my company who played a key role in the success of the conference. Special thanks to Kathleen Repoli, our Chief Operating Officer, and Josephine Hermanson, who works with Kathleen on business development, for dealing with all of the minor and major snafus that popped up along the way.  (I know some of you are probably still having recurring thoughts of being trapped in a freezing conference room without a Wi-Fi connection.)

Highlights of the conference included a preview of what’s coming in Amazing Charts V 5.1. Features that people were very excited about included the Amazing Charts OnCall iPhone App, SureScripts Certification, and tighter integration with pharmacies.  There was a fascinating discussion in the objective review of third-party apps being used with Amazing Charts, and my staff learned a lot about what kinds of tools our user base finds most valuable.  There was a very lively breakout session on Practice Management, which I promised in public to deliver by the end of this calendar year.

We heard and took note of a wide range of suggestions, everything from how to make the product more robust, to how to sell it more effectively.  All of these suggestions are being considered very carefully, and we’ve already identified several that will be put into place soon.

More than anything, we got a sense from users about what works—our amazing technical support department and physician-based approach to software design—and what doesn’t work, like our overly long development of practice management.

My final take away from the conference was a better sense of our users: who they are, what their goals are, and what motivates them to practice medicine.  People buy Amazing Charts for any number of different reasons, ranging from our ratings compared to the competition, to our affordability, to our stance against the “business as usual” practices of insurance companies, government bodies, and the software industry.

But there are certain common traits that characterize the people who are attracted to Amazing Charts.  While many of our users provide primary care, often to multiple members of the same family, there were also quite a few specialists providing great care and services.

Some of our users, practice in underserved areas to populations who have low incomes.  For example, Dr. Glenn Lopez, who told me an amazing story about how he pulls a 35-foot mobile clinic around the San Fernando Valley, treating an underserved Hispanic population to prevent chronic diseases like diabetes.  He charges a flat rate of $15 per visit, and his efforts probably save the Los Angeles healthcare system millions of dollars a year by keeping people out of emergency rooms.  I’m so very proud that he’s an Amazing Charts user.

More than anything, the people I talked with really seemed to be living examples of these particular words of the Hippocratic oath:

I will prevent disease whenever I can, for prevention is preferable to cure.

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those of sound mind and body as well as the infirm.

I’m not saying that a cosmetic plastic surgeon in Beverley Hills who makes $500,000 per year from inserting plastic bags into female breast tissue is a bad person.  I just think he’s much more likely to own a bloated EHR system that cost $40,000 per provider.  (Hopefully I haven’t offended of the plastic surgeons that are already valued Amazing Charts clients?)

But overall, the Amazing Charts Users’ Conference was truly amazing, and we’re already thinking about how to make next year’s conference even better.

Postscript – A blogger recently posted a review of Amazing Charts and its users that really echos many of the positive things I heard at the conference.  You can read it here.

First let me clarify that Amazing Charts is a client/server model and isn’t hosted in the cloud (aka web based) as is PracticeFusion or Allscripts-Mysis MyWay.

Of course I’m biased, but I believe that physicians should maintain their data locally. While, in theory, the web-based “ASP,”"Saas”, or “cloud” model sounds good, the reality is that your charts are only accessible if your Internet is working and the company continues to offer it. Can you imagine if your office charts were locked up, and there was just one key, and the person with that key was – rare as it may be – late or out for a day? The disruption would be significant and frustrating.

Now think of the times you’ve been unable to connect to the Internet, or experienced bizarre unexplained web page loading issues – rare as it may be - and you will get a taste of having a remote EHR database.  Anecdotally, we’ve had clients switch to us after using PracticeFusion and other cloud-based EHRs. Their biggest complaints have been that the delay to open the screens and jump from window to window is significant and makes use in a busy practice not practical.

There are two other serious issues of having your patient data in the cloud. First, just by its very nature, the cloud is more accessible to hackers than your computers behind a router. Even if the cloud security is more robust (and that is not necessarily the case), there is just a much larger number of hackers from around the world who will be trying to hack their way in. There are many fewer hackers who know your computer is sitting behind your router’s firewall and thus fewer who will be trying to hack in. 

The other issue is that your data and EHR will exist only so long as the vendor decides to support it.  Unlike most client/server software, if the EHR vendor goes out of business, you can still start up and use your EHR. If the data is in the cloud that is not the case. For example, in June 2002, GE sent a letter to physician’s using their web-based Encounter EHR giving them three months notice that the product would be shut down (read the news article at http://www.ama-assn.org/amednews/2002/08/19/bisa0819.htm).  Users had to scramble to get their data and to find another system, and many users from that time (who now use Amazing Charts) have told me they would never use a cloud based system after that experience.

To read more of my responses to reader’s questions from the debate click here: http://www.hcplive.com/technology/articles/bertman_questions

What are your experiences with SaaS-type EHRs and cloud computing?

As founder and president of Amazing Charts, I represented the small EHR vendor (although I’m not sure why, since Amazing Charts has more unique practice installations than NextGen, Sage, and most other “large” EHR companies). My opponent was Justin Barnes, representing large EHR vendors as chairman of the HIMSS EHR Vendors Association. He is also the vice president of marketing, corporate development, and government affairs at Greenway Medical Technologies.

Justin is a pretty polished guy who speaks beautifully and has experience testifying before the U.S. Congress. Yours truly is a bit rougher around the edges, and I tend to think more about physicians than politicians. While Justin played his role of industry booster, I played my role of industry skeptic/curmudgeon. This difference in our perspectives came through clearly in nearly every question.

One person asked if the expression “you get what you pay for” is true for EHRs. Justin agreed that generally speaking, yes you do get more value when you pay more for a system. I emphatically disagreed, pointing to recent EHR user surveys that show an almost inverse relationship between the cost of an EHR and its usability ratings. In general, the more costly an EHR, the more complex and difficult actual EHR users tend to find it. (Check out these studies, for example.)

We even disagreed about what defines a “costly” EHR. Justin thinks $1,000 per month per provider is a perfectly reasonable cost for an ambulatory EHR. I think that sum is outrageous. Amazing Charts costs just $995 per provider (one-time charge), and then $500/year for maintenance, technical support, ePrescribing, and essentially everything else. They want $12,000 a year, or more, in perpetuity. Seriously?

Assuming that “large” and “small” EHRs are equally certified (both Greenway and Amazing Charts, for example, are currently CCHIT Certified to the same standards for ambulatory EHRs) and are equally eligible for stimulus money, then what is the difference? It certainly isn’t that the more expensive EHR is better. Again, study after study of EHR users show that the less expensive EHRs consistently get rated easier to use, and have a significantly higher customer satisfaction rating than their “larger” competitors. So if not the quality of the EHR, and not the capabilities of the EHR, then what explains why most EHR vendors charge so much for their software?

I think the reason is simple: greed. Unfortunately, greed often has a negative connotation, and I don’t mean it to. Perhaps a better way to say this is that “large” EHR vendors are focused on doing right by their shareholders, while “small” EHR vendors are more focused on doing right by their users. Let’s look at the facts.

The largest EHR vendors are public companies whose main focus is growing profits, quarter in and quarter out. These companies have massive expenditures associated with being public and live or die based on how Wall Street and institutional investors perceive them. It doesn’t matter how much or how little their users like them – so long as they can use marketing hype and large hospital and group deals to continue to generate revenue.

Most of the private EHR vendors are similarly beholden to shareholders, albeit they don’t have to publically disclose who these shareholders are. These companies have taken money from private equity investors, venture capitalists, and other financial partners who ultimately call the shots. The “exit strategy” is what it is all about – and the VCs aren’t in it to improve the physician’s existence or solve healthcare problems, they want to know how and when they are going to see spectacular returns on their investment. Since they hope to either sell their company to a bigger fish, or bring their company public, they need to squeeze maximum profit margins out of these companies – since that is what it is all about. This, of course, translates directly into higher prices for physicians.

It should therefore come as no surprise that those people who lead most large EHR companies, as well as the leaders of the “small,” VC-funded EHRs, have nothing to do with medicine. These companies are not led by physicians who understand what it is like to try to make ends meet in a practice that must see too many patients a day. These are people from investment companies, tech companies, and other financial firms, and make no mistake about it – their #1 priority is to make money for their shareholders.

Let’s look at some examples. Allscripts-Mysis (MDRX) is one of the biggest of the big boys, and has grown by gobbling up smaller VC-funded EHR vendors. They had revenue of 548 million in 2009, of which more than half was profit! Their main shareholder? Fidelity. And according to the bios listed at morningstar.com, not a single person on Allscripts board of directors is a physician. Not one of their “key” executives (CEO, President, etc) appears to be a physician either.

NextGen (QSII), another huge player, made 246 million in 2009, of which more than half was profit too! Their leadership list is here. It is fascinating to look at the bios of leaders of the expensive EHR (the low priced EHRs apparently can’t afford a webpage with a list). Who leads the company clearly explains the difference in EHR price. Check out Centricity, Sage, and Greenway’s leaders. (Sorry Justin, nothing personal – but your board of directors is like reading the who’s who of the Venture Capital market).

Now don’t get me wrong. I am as much of a capitalist as the next guy – and my goal in running a business certainly includes making a profit, but I think a more logical and worldy approach is a concept I’ll call, “kind capitalism”. Kind capitalism is being fair but still making a profit.

When applied to Amazing Charts, it means we will charge a reasonable price for our product. A price that covers our expenses and development plans, plus makes some extra too. Kind capitalism is not charging so much that a physician has to take out a loan to afford an EHR while half of every dollar made is profit. Kind capitalism is being fair in all aspects of ones business dealings, and really is just an extension of the Golden Rule to capitalism: Do unto others as you would have others do unto you. Not because God tells us to. Not because we believe that Marxism is a better answer. Just because it is being fair. And acting fair, promotes fairness, while being greedy promotes greed. There must be a happy medium.

Call me naive (many do), but I believe building the best EHR I can build, and providing it fairly, is the first tiny step in changing the healthcare system (and eventually the world). The next step? Watch out UnitedHealth…

Big tradeshow booths are just one sign that the entire Health IT industry is being flooded with money. Is it the HITECH stimulus money earmarked for physicians to adopt Health IT? No, not a penny of the so-called “stimulus money” has been collected by any physician yet.

What I’m talking about is VC money, M&A money, and Wall Street money pouring in from all sides. And why is the “smart money” in America gushing into Health IT like it’s the Next Gold Rush?

Could it be that we physicians have a giant target on our backs that marks us unsuspecting dupes just waiting to be separated from our wallets? I’m starting to wonder…

During my three days at HIMSS, I visited many EHR vendor booths as well as the informational booth set up by the Health & Human Service’s Office of the National Coordinator for Health Information Technology (ONC), the organization at the forefront of the administration’s Health IT efforts – and, as their name implies, the folks responsible for coordinating and informing the public as to the actual details of the plan.

My goal was simple. I presented myself as a having a small family practice in Rhode Island collecting $16,000 per year from Medicare – all of which is 100 percent true. I then asked vendors and the ONC how much money I would be able to collect for “meaningful” use of a “certified” EHR system. I asked them whether I would be able to collect the $44,000 that so many vendors promise. I also pressed for specific details, such as how the payments would be made, how often, etc.

What happened next literally blew my mind. I felt like Alice wandering though Wonderland as people said things to me that were not rooted in reality.

First stop, the vendors
Some clear disclosure is in order for those who don’t know me. I am the founder and owner of Amazing Charts, an EHR company whose mission is to provide an affordable and usable EHR to those of us in small practices – so obviously I am biased against the “big boy” EHR systems that I believe use misinformation to unfairly trick physicians into getting gouged. Thus I approached those whom I consider to be “big boy” EHR companies. I spoke to the representatives of a number of these major players in the EHR space, including Allscripts, Athenahealth, Cerner, eClinicalWorks, GE’s Centricity, Greenway, and NextGen, to name a few.

I asked each vendor the same simple question noted above, yet the answers I got from these companies were all over the place – ranging from promises that I will collect all $44,000 under the assumptions I gave them (not true!), to confessions that they were unsure. No two had the same answer, and only one company (GE) had the right answer. This is despite the fact that each one had sales literature and website pages covered with headlines that misleadingly tout the number $44,000. One vendor’s representative even confused the Medicare and Medicaid subsidies, promising me a whopping $65,000 pay day courtesy of the stimulus money.

This would be laughable, until you think about the fact that thousands and thousands of overworked and underpaid small practice physicians are going to pay outrageous sums for substandard solutions, all in the false expectation of some giant windfall at the end of the day. Shame on EHR vendors! Who do you think will get the short end of the stick when a physician misled by unscrupulous EHR vendors spends tens of thousands of dollars on an overpriced EHR?

Next stop: ONC
Okay, as a taxpaying citizen I figured the government office overseeing all this money should be able to clarify the vendor confusion and provide me some correct answers. In fact, several vendors pointed me to the ONC when my persistent questioning annoyed and/or confused them.

I spoke to five different people at the ONC booth—all of them were Federal officials at one level or another—yet not one of them could answer my simple question.

The first person said “I can’t tell you – it’s more complex than that…” They had to go get someone else. The second person said I would get $44,000 over three stages, clearly confusing the three stages of meaningful use with the five-year period during which physicians may collect incentive payments.

A third person who presented herself as the Director of Communications of ONC said she didn’t know the details, but was sure that the second person knew what she was talking about. Still another ONC rep said, after going to check with somebody from Medicare, that I needed to meet a minimum threshold of $24,000 in Medicare payments before I could collect any money. As an aside he offered that I should increase my Medicare population.

The fifth person said all the information was on the ONC website, but then could not find the information when I asked her to show me. Wrong, wrong, wrong, wrong! Shame on the ONC! Again, who do you think will get the short end of the stick when a physician misled by uneducated ONC representatives spends tens of thousands of dollars on an overpriced EHR?

So what is the reality?
The simple answer, which not one of the five officials from ONC could provide, is that you will be able to collect the lesser of up to 75% of your total Medicare allowables (aka collections) in each of the five years beginning in 2010, or a maximum annual amount that changes year to year as shown below.

$18,000 in 2011 (or 75% of Medicare collections, whichever is less)
$12,000 in 2012 (or 75% of Medicare collections, whichever is less)
$ 8,000 in 2013 (or 75% of Medicare collections, whichever is less)
$ 4,000 in 2014 (or 75% of Medicare collections, whichever is less)
$ 2,000 in 2015 (or 75% of Medicare collections, whichever is less)
= $44,000 total from Medicare (if you collect $24,000 or more from Medicare each year).

So while it is true that you could get up to $44,000, what many vendors fail to explain is that if you collect less than $24,000/year from Medicare, you get less. In other words, the correct answer to my question is that I should be eligible to receive $38,000 so long as I use a “certified” EHR in a “meaningful” way. (Believe it or not, to date there is not one recognized “certifying” body, and the definition of “meaningful use” has not yet finalized. But that’s a blog entry for a different day.)

Rapacious EHR Pricing Schemes
Beyond the alarming inability to get a straight answer from those who should know, there are a few other troubling observations regarding the HITECH legislation that I believe deserves closer inspection.

First, why is it that the head of one of these ludicrously priced EHRs is the President’s Health IT advisor? It would be difficult for any EHR vendor, let alone one whose software (coincidentally?) costs the same as the amount the government is willing to pay, to provide recommendations that benefit physicians and taxpayers over vendors.

Second, and what I see as one of the most flagrant examples of the EHR Industry’s focus on taking every penny of this stimulus money from physicians, is that some vendors told me that their high monthly pricing will drop after the stimulus period is over. There were a few vendors who quoted me a price of $699/month during the stimulus period ($699/month x 12 months/year x 5 years) for a total of $42K. Sounds coincidentally similar to the $44K maximum, no?

Don’t forget – these are our tax dollars. Why should the money be wasted on overpriced EHRs when there are higher-rated solutions available for a fraction of the cost?

There is some good news in all of this. Despite the misinformation from a few of the vendors with whom I spoke, the stimulus money is completely unrelated to the cost of your Health IT expenditures. In other words, physicians who select a more affordable EHR will get to pocket the stimulus money instead of giving it to an overpriced vendor. Better still, each physician who avoids being suckered into paying tens of thousands of dollars to benefit corporate shareholders sends a clear (and long overdue) message to these big businesses: we’re sick and tired of seeing unfair and unethical corporate behavior, and we’re not going to take it anymore!

What do you think?

Impact on Amazing Charts and Other EHRs
Amazing Charts V5 is a CCHIT Certified 08 Ambulatory EHR additionally certified for Child Health. Companies like Amazing Charts that have already gone through a preliminary round of CCHIT testing for the government requirements will have to go through a completely new set of tests – and will be re-charged another $43,000 for this certification. The ridiculous pricing by CCHIT is one of the reasons that HHS is working to have other certifying bodies available, but currently only CCHIT looks (nearly) ready to be an officially-recognized certifying body. Yet, currently CCHIT is not – and, in fact, there is no officially-recognized certifying body – meaning currently there are no EHRs eligible for the ARRA HITECH Stimulus money most EHR companies are advertising as a way to combat the sticker-shock of their price tag.

New Competition for CCHIT?
HHS put out its rules last week for selecting organizations that will certify EHR technology against the government requirements. While Amazing Charts has already paid $43K and reached CCHIT 08 certification (since some insurers reimbursed physicians better if they use a CCHIT 08 certified EHR), CCHIT definitely needs some competition to encourage them to lower their pricing. In my opinion, CCHIT’s high price prevents smaller and start-up EHR companies from entering the market. And the more competition in the EHR industry, the faster EHR usability will improve and EHR pricing will decrease.

Temporary vs. Permanent Certification
Like everything our government touches, there must be an extra layer of complication. There will be a temporary program to certify EHR technology against the Stage 1 Meaningful Use requirements in 2010 and 2011. A permanent certification program will be put in place by the beginning of 2012, or so they say.

The main difference between the temporary program for 2010-11 and the permanent program is the fact that HHS is going have the National Institute of Standards and Technology (NIST) start to test the capability of organizations like CCHIT to evaluate EHR technology. HHS is going to sign off on the evaluation capability of CCHIT for the temporary program, because it would take too long for NIST to set up a process for evaluating the testing capability of organizations like CCHIT.

What do you think about the government’s decision to halt CCHIT certification testing?