SOAPware Release Status

After 7 months of testing and private beta, SOAPware 2010 has now gone into public beta. Even though it is a beta, it is much faster and more stable than the current release of SOAPware 2008. As of yesterday, it appeared that 14 sites had installed it. It is not possible to determine yet how many are using it live, but probably half are doing so. So far, few problems have been reported, so we are hoping we will be able to go into a full release sooner rather than later. This first installer is only for SOAPware 2008 upgrades, but next week we hope to complete the installer for versions prior to 2008. From there, we can start merging in the advanced e-prescribing and the billing system. Subsequent to that, we will be working on simplifying workflows and advanced SMARText management as we incorporate more robust information exchange (e.g. registries, portals, etc).

Poll on effect of Stimulus Bill on EMR adoption

Houston Neal over at the software advice blog is running a poll on Obama’s EMR/EHR Stimulus of 2009 – Creating Buyers or Tire Kickers? Click on the link, and another couple of clicks is all it takes.

My Recent Interview at the EMR and HIPAA Blog

A good blog to follow is EMR and HIPAA. John is doing a great job of telling it like it is rather than just sipping the spiked industry punch as a majority of industry shills seem to be doing. I was pleased to offer a recent interview:

October 21, 2009
Interview with President of SOAPware EMR – Randall Oates
Written by: John

I invite you to visit and follow that blog, and here are what I consider the main points I offered in the interview.

…2005 to present – Focus (i.e. the SOAPware team has focused) on transition to next generation, comprehensive EMR – We retreated from major marketing, and engaged a complete rewrite of the software. We are now focusing almost all resources on completing the product suite and simplifying what is presently an often overly-complex interface…

...Even though we will soon release our fully integrated system, we will continue to work with interfaced solutions...

...The paper superbills physicians tend to use, today, will have to expand from one page to at least ten pages (i.e. 2013-2015). This, along with the need for clinicians to perform accurate reporting of “performance measures” at the point of care, will likely render interfaced systems (with billing clerks expected to enter the data) as too cumbersome and limited to be practical...

...We already have waiting times for our training services, and this is likely to worsen in the short term. Long term, we are engaging several initiatives in order to be able to quickly scale up for the demand. Not only are we hiring more training staff, but we are creating a new “partner” program that is fairly unique. For example, our current users will be encouraged to become certified SOAPware trainers in their own communities. (Intuit has done this with great success with QuickBooks, and disrupted an entire industry as a result.)...

...We will definitely be going for HHS certification so that our users can qualify for the ARRA bonus payments. Whether or not we will also go for CCHIT certification in the future remains to be determined. Presently, CCHIT is the only entity on the immediate horizon to certify for HHS, but other certifying entities are likely in the works. It is just too early to announce who we will utilize for future, HHS certification...

...SOAPware can either be used either as paper behind glass or as a comprehensive system collecting real data. More importantly, our design facilitates a gradual migration from the simple free-text narrative to as much structured data as is necessary, and in fashions that are less likely to lower physician productivity along the way...

...The other down side to DNS (i.e. Dragon Naturally Speaking) is that it does not yet function ideally in either ASP or cloud-based solutions. While the past ASP approach to delivering technology solutions to practices has not seen great success, the emerging cloud-based solutions will likely trigger the EMR revolution. For example, our hosted, cloud-based solution, allows for the practice to have their own virtual server in the Internet cloud. This removes the expense and hassles of attempting to maintain a clinic server, network, back-ups, etc, but the practices are not just limited to only the software and solutions that the typical, more limited ASP approach can offer. I just hope the engineers can figure out how to make speech recognition more fully compatible with these hosted, virtual, or cloud-based solutions before the end of 2010.

...What is mainly missing (in the EMR industry) is an accurate perception of reality. That is… recognition that it is nothing less than insanity to expect physicians to become data entry clerks! In the future, we are going to look at the current approaches to EMR implementation in the same fashion as we now view the practice of leeching and blood-letting of the past...

... (Missing in the industry) A proper understanding of the necessary process changes practice need to make before even considering the available EMR solutions is generally missing. Along with this is a dearth of approaches advocating tolerable, incremental evolutions...

...We are missing standards allowing for the sharing of information that is patient-centric rather than industry-centric. The former tend to be easier and more practical for patients and small medical practices. The later tend to be what the current, moneyed-controlling entities in healthcare prefer...

...EMR’s need standards in order to be more open-platform in order to support best-of-breed solutions. No single vendor can deliver a monolithic application that is ideal for almost any specific practice...

...We have a very large community of SOAPware version 4 users (i.e. paper behind glass method) that now need to begin the process of migrating to more comprehensive use of information. This needs to be properly managed via clinician leadership and practice readiness assessments in order to be most efficient. These practices need to upgrade within the next few months, because the second half of 2010 needs to be free to add in the registry (i.e. population reporting) and patient portal (i.e. electronic communications) that are to follow the release of our integrated billing system. Again, these, more comprehensive functions, need to be added only after careful planning and practice preparation...

I wish I could come up with some little pithy witticism at this point. However, the problem with any humor regarding this industry (as with Jonestown) is that that joviality tends to either be a little on the dark side, or the punch lines are too long.

Now is the Time, Here is the Path

Below, are quotes from - Ten Steps to a Patient-Centered Medical Home
Family Practice Management
September/October 2009
Anton J. Kuzel, MD, MHPE


...While these projects have obvious merit, I want to suggest what may be a simpler approach – one that does not depend on new models of financing and that follows a logical series of steps, each building on the one before to develop the capacity and infrastructure for a high-volume practice capable of sophisticated population care and management...



Step 1: Improve documentation and coding.

Step 2: Hire more nurses or medical assistants.

Step 3: Implement advanced access scheduling.

Step 4: Increase the number of patients you see per day.

Step 5: (Optional) Expand hours

Step 6: Buy and implement an EHR.

Step 7: Start doing systematic, population-based care.

Step 8: Buy and implement a patient portal.

Step 9: Work with local health systems to create electronic linkages.

Step 10: Improve management of high-cost patients.


...It seems to me that we have a clear opportunity to make our practices and our health care system much better than they are now, and we may actually already have the needed resources. It’s time to get started...

I greatly encourage a vist to this very valuable article to learn the essentials of this journey.

There Are Risks During the Interval Until the k-EMR is Available?

In an earlier post, I described some of the main characteristics of the k-EMR. it does not yet exist.

Just about all the evidence indicates our impending national investment to promote current health information technology solutions is on a a tragic course to trigger even more skepticism and distrust by physicians and their patients. This is because present EMR initiatives (based on multiple, published surveys), are delivering failing solutions to the majority of medical practices. The evidence confirms that most physicians lose productivity because they are converted into data entry clerks. Patients, more often than not, end up with less, rather than more access to their trusted physicians.

Why spend a lot of effort and money until there is a proven path that at least provides a critical mass of efficient data generation and connectivity for physicians and their patients?


What evidence is there, anywhere, that the value propositions of current EMR initiatives being proposed (i.e. by those who are not patient representatives or their physicians) are wise investments for medical practices?

The EMR Market Challenge and Opportunity

Few EMR customers perceive the importance of the necessary process change, so few will budget for it. They confuse implementation with training. Training is the 1/3 and implementation the 2/3rds.

Resources, that practices adopting EMR's currently allocate to software/training, need to be shifted to implementation.

Avoiding Failed EMR Implementations

$598 million from the ARRA Stimulus Bill is to be directed toward delivering the process change in small practices in 2010.

How the Feds will spend the first $1.16 Billion on HIT

Will the first $598 million really be invested toward meaningfully facilitating the change process that is necessary in typical medical practices? Or, will it be more of the same, flawed approaches?

More on EMR Failures

From -Healthcare Informatics
Posted on: 7.31.2008 6:13:49 PM

EHR Failures: Can We Do Better Than the Average?

The following are exerpts from Healthcare Informatics. Please visit this site for the full story and others of value.

...To further develop this point: It’s difficult to distinguish between EHR failure rates that apply to physician practices vs. hospitals, but here are some of the percentages that are quoted:

- Oh no! Half of all current EMR’s fail! Technology for Doctors, 2007

- 19% of EMRs are uninstalled; 30 percent are not used by at least some physicians, Medical Records Institute, 2007

- Avoiding EMR meltdown: How to get your money’s worth (“About a third of practices that buy EMR systems stop using them within a year”) AMNews, 2006

- The failure rates of EMR implementations are…close to 50%.” Proceedings of the 11th Annual Symposium on Health Information Management Research, 2006

- “Industry experts estimate that failure rates of EMR implementations range from 50-80%.” A Commonsense Approach to EMRs, 2006

- “50% of EMR system implementations result in failure.” International Journal of Technology Assessment in Health Care, 1997

To use the lowest figure cited, let’s say that approximately twenty percent of hospital EHR installations fail and the system is removed. In these cases it’s likely that the entire investment in hardware, software, implementation costs, lost productivity (and other costs more difficult to measure) is lost. If this average investment is ten percent of annual revenues (or $100 million for a $1 billion IDN) the other 80 percent of EHR implementations must generate a return of 2.5 percent of annual revenues each just to get back to even.

Under these conditions, the relatively small number of very successful installations is not enough to pull the average EHR return into positive territory, and the CBO is right in concluding that “By itself, the adoption of more health IT is generally not sufficient to produce significant… savings”.

But what if you could increase the chances of success? Make it much more likely that your EHR would succeed than fail? Then the benefits demonstrated by the successes are well worth the investment. That’s the question at hand for hospital executives: “Can we do better than the average?” I believe the answer is yes, especially since the bar is set so low, but it will require a different approach to EHR implementation, one focused on system value (benefits) instead of just technical success or process changes.

As a long time owner of a technology training company and former CIO of an international technology training company I can say that what you are seeing in the EHR implementations is no different than what industries saw years ago in implementations of ERP applications such as SAP, Oracle, Bond and etc. Maturity has solved a part of their issue by understanding that a technology implementation is 80% change management/education and 20% technology.

Training is a key component to the success of a technology implementation that encompasses the change management and teaching the end user how to effectively utilize the new technology. The old "super user" training model does not work, but time and time again I hear and see that change management and training are merely an after thought at the end of an implementation. Assessing the trainee population is overlooked and an assumption that all users already have the requisite knowledge of computer usage is wrong... In fact in recent surveys, over 30% of the working public cannot effectively use a computer or navigate the internet, but yet we question why the adoption rate for an EHR implementation is so low and ends up in failure. Many implementations depend on a system analyst to design and configure the workflow and associated applications set up, then create training materials and deliver training! No wonder we have failures. Such little thought or importance put into what might be the most critical aspect is a formula for failure. Professionally designed courseware utilizing advanced adult education concepts, creating standard content templates, and measuring the effectiveness of training are all a part of a well defined implementation.

A few key considerations:

Who needs to be trained?
What do they need to know to do their job?
When do they need to be trained?
What is their base knowledge of the technology?
What do we need to do to have them at a minimum knowledge level prior to go live?
What resources are required?
How are we going to register, track assess and monitor training?
How are we going to deliver training?
How are we going to get our delivery staff prepped?
Do we have Executive buy in?
Are employees and management aware of the time commitment to get trained?
Do we have an effective communication plan including gathering and using feedback?
How are we going to measure the effectiveness of our Change Mgmt/Training program?
Have we adequately budgeted for training? ...



I encourage you to ask how your approach to EMR implementation is similar to and different from the current approaches to EMR implementation?

Based on the approach that you are taking, where is there any hard evidence that your likelihood of success can be any greater than the industry norm?

Who was it that said that those who do not study history are doomed to repeat it?

Current EMR Sales/Marketing Approaches are Misguided

To be economically viable, today, the industry has largely had to focus sales and marketing efforts primarily upon products/services to serve the minority of practices that are atypical (i.e. early adopters and large and/or integrated practices). Both of these practice types contain resources beyond what is available to most physicians. This, combined with the fact that busy physicians are too challenged today with just surviving so that the scope of the change seems all but overwhelming. As a result, most practices will fail to be able to deliver the data needed to meet "meaningful use" without active facilitation. There is a continuum related to practice readiness for EMR and patient-centered collaborative care:

• 20% of medical practices can change their process without much need for outside facilitation.
• 20% of medical practices can utilize implementation surveys, checklists, peer groups and succeed with minimal facilitation.
• 60% of medical practices need active facilitation that is often on-site and more specific.

Real World Lessons in Practice Transformation

More – Real World Lessons

What if there was some nature of vetting, as to readiness, that is part of the pre-implementation analysis before EMR vendors were willing to sell into a practice?

The Process Change Necessary to Implement an EMR

Again, EMR Implementations must start with the process rather than the technology, and must go through the following sequence to avoid high failure rates:

1. Pre-Implementation Practice Readiness - Issues are independent of EMR choice.
2. Implementation Change Management at Go-live - Issues are inseparable from EMR.
3. Continued Evolutionary improvements - Issues are inseparable from EMR.

• High Performing Patient Centered Practices
• A Remedy For Health-Care Costs
• A Medical Record Carol?

I continue to be amazed as to how few in the industry are really addressing this necessary, fundamental change process. However, a chosen few that have made strides. Examples include TransforMED and a few medical societies and quality improvement organizations (e.g. Monroe County Medical Society - Dr. Ali Loveys). The real challenge is less the creation of the necessary implementation surveys/checklists, and is more about having facilitators available to the practice that know how to use these tools within diverse practices that have limited resources.

Why The Current Impetus Toward HIT Is So Problematic

(This is more of a summary post of many previous ones.)

Solutions are too expensive.

The tendency is to advocate physicians adopt information technology in a fashion that creates chaos, and typically starts with the 10th ladder rung, rather than the first.

Approaches typically trigger loss in physician productivity not acceptable by a majority of practices.

• EMR Risks and Realities

• EMR De-installations – A Growing Trend?

• Physician Instructions on How to Plan to Fail with EMR Implementations

• Report: Stimulus Package Might Now Spur Health IT Adoption

• Another dirty secret… EMR Failures

• The “Field of Dreams” Myth and the Health Information Technology Industry

• “Field of Dreams” Entertainment in HIT

• The Open Source “Field of Dreams”

• The “free EMR from the hospital” Field of Dreams

Again, physicians are not great brick-makers or data-entry clerks. However, the basic data items are the bricks in the foundation of everything else.

• Clinicians are not data-entry clerks!

• Data granularity is important in the EMR

As I said in a previous post, If there are not fundamental process changes in how the data, originating from patients, and the physicians they trust, is created, all the elegant, higher level solutions promised by the industry and the government are likely to be little more than technotitillation.

Why advocate existing solutions that have top-down technology approaches promising a >80% failure rate delivering the data?

The SOAPware Story

Several have recently asked for more history about our company. Below is an outline:

• 1987 to 1992 – Prototype stage - I created the prototype for SOAPware using a program called Hypercard on early Apple Macintosh computers while building a very large and active medical practice in Springdale, Arkansas.
  
  
• 1992 to 1994 – Start-up - Greg Lose came in to turn the prototype into a real product.
  
  
• 1994 to 2005 – Market dominance in small practices - David Powell came on as CEO. In 2005, there was not an EMR product installed in more sites than SOAPware.
  
  
• 2005 to present – Focus on transition to next generation, comprehensive EMR - We retreated from major marketing, and have focused almost all resources on completing the product suite.. A need for integrated billing system has accentuated SOAPware’s retreat in the marketplace. In 2004, only 12% of new EMR customers were shopping for a combined EMR/PMS. Now, it is over 70%. This emphasizes our need to have the fully integrated product as soon as is possible.

Greg, David, and I remain as the principals in the company. One year ago, a fairly accurate summary was published at MDNG - The EHR Trailblazers

Perhaps the NHIN may not turn into a boondoggle?

Yet again, John Chilimark has provided the best summary-overview, that I have seen, of a possibly significant event in the rapidly evolving world of health information technology.

Below are excerpts from - NHIN: The New Health Internet?

"Chilmark has not been a big fan of the National Health Information Network (NHIN) concept. It was, and in large part still is, a top heavy federal government effort to create a nationwide infrastructure to facilitate the exchange of clinical information. A high, lofty and admirable goal, but one that is far too in front of where the market is today. The NHIN is like putting in an interstate highway system (something that did not happen until Eisenhower came to office) when we are still traveling by horse and buggy. Chilmark has argued for a more measured approach beginning locally via HIEs established by IDNs (our favorite as there is a clear and compelling business case) and RHIOs in regions where competitors willingly chose not to compete on data, rather seeing value in sharing data.
But what might happen if the folks in DC stopped talking about the NHIN as some uber-Health Exchange, but instead positioned it as a consumer-focused platform?
That is basically what happened yesterday at the ITdotHealth event where the new federal CTO, Aneesh Chopra and new HHS CTO Todd Park presented their conceptual idea to a pretty select group who had gathered together to discuss the idea of platforms in HIT to support discrete, substitutable, modular apps. (John Halamka gave a nice write-up of the event in which he participated on the first day). Chopra and Park were seeking to float this idea among the movers and shakers of new models for HIT, gauge the interest and ultimately solicit support for the concept.

Chilmark is very encouraged by the idea of the Health Internet and the new direction it is taking, creating a consumer directed and controlled interstate for the secure transfer of PHI. Not only does it finally acknowledge that at the end of the day, all the HIT spending in the world will make little difference if we do not get the one who has the most to gain, the consumer, involved, but this initiative may also create a fertile environment for innovation to occur."



My Comments and Questions:
Indeed, this event along with some of the rules regarding the creation of the Regional Health Information Technology Extension Centers offer a little glimmer of hope.

How many understand that if there are not fundamental process changes in how the data originating from patients and the physicians they trust is created, all the fancy, top-down solutions promise to be little more than a lot of expensive technotitillation?

How many in the industry and government are still mostly focused on technotitillation rather than creating the the necessary bricks that are the foundation? Who has realized that physicians are not great brick-makers or data-entry clerks?

Who has a clue that absent the data from the patient-physician interface, none of the rest of it matters very much?




"Insanity: the belief that one can get different results by doing the same thing."
-Albert Einstein

Tentative SOAPware Product Release Plans

SOAPware 2010 Pre-Release - The SOAPware version that has been in development throughout 2009. It is much more stable and faster than SOAPware 2008 and contains an enhanced prescription manager. Likely to be released in 2009.

SOAPware 2010 – This is the SOAPware version containing the complete e-prescribing tools that includes forumulary, eligibility and histories of prescriptions filled. Likely to be released in early 2010, but release is dependent on testing and number of cycles through quality control.

SOAPware 2010 + Billing - This will contain our integrated billing system in addition to everything in the earlier 2010 releases. Likely to be released in early 2010, but release is dependent on testing and number of cycles through quality control.



Comment:
In February, we had basically completed major development on SOAPware 2009 except for the enhanced electronic prescribing. Creating the most efficient and useful e-prescribing interface, considering all the current and near future requirements (has been a moving target), added many more months to the cycle than we have anticipated.
Quality Control issues have also caused us to delay the release of what has been called SOAPware 2009. This version has addressed hundreds of issues that are present in SOAPware 2008, and is currently a far superior product to SOAPware 2008. There are still quality issues to address, but it is so much better than 2008 that we need to proceed with a release, this will be the 2010 Pre-Release.
This past week, we officially completed certification for the advanced e-prescribing capabilities, but this is a huge development branch that now needs merging into SOAPware 2009.
We are at the alpha stage with our integrated billing product, but this is also a huge development branch that now needs merging into SOAPware 2009.
Each time a development branch is merged, there can be quality issues, so we intend to take a stepped approach as above.