Gotcha!

trap!

More thoughtful analysis of the American EMR experience courtesy of the KevinMD.com website.

It is becoming apparent that more and more EMR users are finding themselves trapped with an EMR that they either did not want, or that they signed up for only because of fire sale prices enabled by government subsidization.

Hmmmm… sounds familiar…

The result is that customer satisfaction is in freefall.

Yet more evidence that the New Brunswick approach of “my way or the highway” is wrong.

Dead wrong.

Read on to find out why, and how we could do things differently here:

I Despise My EHR, But I’m Still Using It

Setting the record straight…

Bad!

I received yet another public scolding from the leadership of the New Brunswick Medical Society recently.  It really is getting a bit tiresome.   “Sit down and shut up” might have worked well for badly-behaved elementary student in the 1960’s, but this is 2014, I am 56, and it’s not working at all for me.

Here’s what Dr. Hansen had to say on March 18:

Provincial EMR program in the news

I was pleased to take questions from the media about our EMR program. With over 250 physicians already enrolled for the program, I believe it is quite likely that we will hit the Department of Health’s estimate of 300 physicians in our first year of operation, which is quite an achievement. The Minister of Health has recently stated that he is open to renegotiating several elements of the Program, which is good news. We look forward to addressing some challenges with the Program with the Department of Health while we move forward with dozens of implementations over the next months. Velante is already the largest EMR provider in the province. Members are reminded that there are only two weeks left to enrol!

I must say that I am personally disappointed at some of the criticisms of the program and more directly, public attacks against the leadership of the NBMS. Some have gone to the media without voicing their concerns to us first; others have made claims that are inaccurate in public fora. There are legitimate concerns about this new and fast-paced program, and some have been raised in proper forums for informed discussion and debate. Some members will not choose to adopt the Velante program, and that is an understandable decision. But to be clear, the EMR program is similar to those in other provinces; costs taxpayers a fraction of some estimates made by members in the media; and no patient’s health information is being kept from any health provider. We look forward to discussions with the Department of Health to improve the program and will endeavour to better explain the Program’s details to members.

Lets just set the record straight on a few issues which seem to be a bit off the mark in the latest President’s Letter from the NBMS and in the imbedded links in the original document:

1)  Velante is NOT a physician-run company.   It has a seven member board of directors.   Two of the directors are doctors.   Three are Accreon executives, one is the CEO of the NBMS (who is NOT a doctor), and one is a UNB business professor.  That’s the way it was in October.   Correct me if I am wrong.

2) I did not go “to the media.”  They came to me.   I turned down invitations for interviews twice before Minister Flemming came out with the news that Velante was failing to meet conscription goals.

3)  I DID go to the NBMS multiple times with concerns about the EMR program.   I got the distinct impression that nobody was listening.  One letter I sent to the President went unanswered for two months.  I finally got a reply when the media started to question the viability of the Velante plan.   The reply I got was more of a reprimand than an answer to my legitimate questions.

4)  At last fall’s NBMS Annual General Meeting, the membership approved a resolution which directed the NBMS to not interfere with doctors using other EMR products interconnecting with Department of Health computers.  The leadership did not follow the direction of the membership and continued to obstruct early adopter of EMR technology.

5)  At the AGM, the CEO of the NBMS denied the existence of the secret Data Sharing Agreement, despite the fact that he had signed the document three months earlier.   We only found out about it after another doctor used right-to-information legislation to get a copy of it.  The CEO has never explained how he was able to sign this agreement and then seem to be unaware of its existence.

6)  Velante is not the the largest EMR vendor in the province.   At last report there were 34 people using a limited version of the advertised product.   Practice Solutions has 60 or more satisfied customers who received no handouts and were happy to pay the going rate for a top-quality, fully-functional EMR.

7)  The Minister of Health did say he was willing to renegotiate the secret Data Sharing Agreement.  What Dr. Hansen fails to mention is that the leadership of the NBMS refuses to even discuss permitting more than one approved software vendor, in defiance of the wishes of the membership.

The bottom line:

Increase in fee-for-service payments to doctors over 4 years (if the contract is ratified):  4%

Increase in NBMS membership dues over the last four years: 39%

Number of taxpayer dollars being offered per year  to convince doctors to jump aboard the S.S. Velante:  $1,500,000

Number of doctors in New Brunswick:   1600

Number of doctors who signed a form indicating they are interested in EMRs:   350

Number of doctors said to be using a limited version of the Velante product:  34

Number of doctors using the Velante product who will tell you that they are satisfied with the Velante product, and that it has lived up to the claims of marketers:   ???

The leadership of the NBMS is pulling out all the stops in its effort to bail out Velante.   The latest move uses taxpayer money – redirected from a general fee increase – to try to convinced the many satisfied Telus Health and Oscar users to jump ship.   Problem is, we don’t want the money.   We like our EMRs, and we can’t be bought.

Make no mistake about it, medicine in New Brunswick is under an all out attack by those who wish to shape healthcare in their own image.   The NBMS, like Nero, fiddles while Rome burns, and Accreon is calling the tune.

By what authority has the leadership of the NBMS transformed our Society from its traditional role as protector of patients and doctors to a public relations company for a failing information technology project?

Remember, not a single New Brunswick doctor was using Intrahealth software prior to the Velante scheme.   The only reason anyone uses it now is because salaried doctors were given the system for free, and a handful of fee-for-service doctors were given thousands  of taxpayer dollars as an incentive to adopt the system.  At least one Saint John family doctor has been offered the Velante system for free, because he trains a lot of residents, and Velante clearly subscribes to the “get ’em young and bend them to your will” philosophy.

Any reasonable person would conclude that a product that cannot sell itself on its merits and survive without government subsidy is not much of a product.   Yet this is exactly the sort of product that the NBMS has chosen to offer us as the ONLY authorized software package in the provincial EMR system.

There are better systems available, but our Medical Society doesn’t want us to use them, and is willing to throw money at the problem until doctors either knuckle under to their will, or the Society is bankrupt.

Stop the merry-go-round, I want to get off.

End of an error…

Dinos

Physicians thinking about using electronic medical record software in New Brunswick woke up April 1st to a new and better world.

Gone is the golden glow of cash handouts, offered through a federal subsidy program called Canada Health Infoway. In its place, a new, more level playing field for EMR vendors in this province.

Up until now, the process of choosing and implementing an EMR was subject not only to one-sided marketing efforts by our own professional society, but also heavily influenced by the offer of taxpayers’ money to offset initial setup costs.    In effect, every taxpayer in the country – every store clerk, cab driver, teacher, firefighter, farmer, and soldier – was helping New Brunswick doctors to pay for their fancy new Velante electronic record system.

Is that fair or appropriate?

Not at all.

Doctors are well paid for the admittedly difficult work we do.   The process of migrating to electronic medical records should not require tapping into funds which might be better used elsewhere.   If the federal government wants to give handouts to doctors in New Brunswick, why not offer incentives to new physicians to move here and help care for the tens of thousands of citizens who do not have a family doctor?  There are dozens of ways our tax dollars could be better spent.

Instead, doctors who have been earning good living in NB were offered a gift of taxpayer money to buy a specific EMR product… and that is just wrong.

True EMR believers – and there are many of us – are more than able to shell out the required money to start using electronic medical records.    About 100 of us have done just that.  Although our patients and the public recognize the investment made by early adopters of EMR technology, not so our own New Brunswick Medical Society.   Instead, when we ask to be treated fairly and equally, we are criticized for having the audacity to question the wisdom of the Velante monopoly and the secret, exclusionary Data Sharing Agreement.

Essentially, people like me are being told by the President of the the NBMS to sit down and shut up.

The problem with the subsidy program was that it was being used to lure physicians who might not be entirely sold on the concept of a provincially-sanctioned EMR monopoly, to buy into it in nonetheless, in order to take advantage of the limited time offer of “money for nothing.”   As a result, doctors were being rushed into making hasty decisions, and encouraged to “enrol” with Velante without thinking through the consequences of their actions.

Above all, New Brunswickers must avoid the establishment of an exclusive, single-vendor EMR monopoly.

Monopolies are bad for business.  Bad for doctors.   Bad for patients.

I cannot think of a single business monopoly which has been good for customers, and it baffles me to think that there are people who continue to push for such a disastrous concept.

Choosing the best EMR product for a medical practice is no easy task.  There is no “one size fits all product.”  It’s best to look at a few different options, talk to people you know who are already using EMR software, and then think about why you want an EMR in the first place.   If after careful deliberation, you decide to go ahead with implementation, there are many different options.

Taking the time to do your research will avoid untold grief further down the road.

 

 

 

The shape of things to come…

Image

The Minister of Health announced today that his department and the New Brunswick Medical Society have agreed upon a new contract for New Brunswick fee-for-service doctors.  No details are available at this time and the agreement will not be in force unless it is ratified by the affected physicians.

I have never had much luck predicting the future, but that doesn’t stop me from trying.

Here’s how I expect it will play out…  figures are approximations only.

There will be no raise in the new contract.   There will be a one time offer of $16,000 for any doctor who signs on with the Velante EMR program.   NBMS will pitch it as a clever way to extend the handout previously offered via the Canada Health Infoway.   They will claim it amounts to an effective 4% increase over each of the two years of the contract, assuming average gross billings of $200,000 ($8000/$200,000 x 100 for two years).  Those who have already qualified for Infoway funding will get nothing (but who cares, they are already caught in the web).  Those who refuse to switch EMRs will also get nothing and will be deprived of the fee increase they might otherwise have received.

From the Velante perspective this is brilliant.   It effectively extends the “pot o’ gold” for another two years and presents doctors with a choice of getting nothing, or getting a handout for buying the Velante product.  It is even possible that the government will get sucked into paying the money up front for any “enrolled” physician, where it can be invested, or used to pay the Velante staff, or incrementally doled out as the sales folk continue to badger more people into signing on.

From the DOH perspective it is also brilliant.   It gives the illusion of offering something of value to doctors.   However, the underlying DOH assumption is that doctors didn’t like Velante before, and they won’t like it now.   DOH will end up paying virtually nothing because very few fee-for-service doctors will buy into Velante, and the DOH will have neatly and effectively dodged any fee increase for doctors.

The only people who won’t like this scheme are doctors.    We have already determined that the Velante plan is doomed and physicians don’t like having it crammed down their throats.  Doctors will be left with the equally unappealing prospects of getting 0% and 0% on the contract, or reaching for the cash and buying into an EMR program we don’t like and don’t want.    If we complain we will be painted as not being team players, or moneygrubbers.

Nice.

If this, or something close to it, is the deal that is offered, doctors should vote it down and send both parties back to the drawing board.

The fee-for-service contract must not be linked to the EMR program.   They are separate issues and the provisions of the former must not be used to coerce doctors in to accepting the latter.

Where’s the beef?

Image

I need a second set of eyes on this.

I was looking at the Canada Health Infoway site to see what sort of help might be available for doctors hoping to implement an Electronic Medical Record in New Brunswick, but despite the fact that there are several other provinces listed, there appears to be nothing for NB!

This raises the question: is there in fact any sort of subsidy for people who sign on to the Velante system?

Or has that ship sailed?

We’ve been told the federal funding flowing through the provincial Department of Health had been extended to the end of March, but there is no evidence I can see on the Canada Health Infoway which would corroborate this.

Have a look at the site:  Canada Health Infoway

Am I missing something?

Keeping an open mind…

brain

 

Benoit Essiambre is a Moncton-based software developer with a keen interest in seeing an end to the Velante monopoly.   His vision of the future of electronic medical records in New Brunswick stands in stark contrast to the exclusionary “take it or leave it” philosophy of the New Brunswick Medical Society and their wealthy business associate Accreon.   Essiambre would like to dismantle the information silos that have been cobbled together for private profit, and foresees a day when we are free from barriers to open, yet secure, exchange of health care information.

Here’s what he has to say:

As a software developer, there is one aspect I feel qualified to comment on which didn’t get much attention and may explain NBMS’s mistakes with Velante.

To software guys like me, it is obvious that when choosing software, one of the most important aspect to look at is vendor lock-in. This has been well known in the software world for a long time. Non technical organisations are starting to realize it too. For example, the UK government has a guide (https://www.gov.uk/service-manual/making-software/choosing-technology) warning of lock-in when choosing software.

In the private world companies are quite averse to lock-in from other companies. That is why open source is gaining so much popularity in the tech business world. One area where it is particularly critical to not bestow control is core data infrastructure. By this I mean the systems that holds the most important data and that controls how and what other systems interface and communicate with it.

Medical records are one of the most important documents in the medical world, so it makes absolutely no sense to stash them in a single system controlled by a single private company and let them charge for access.

This doesn’t mean that proprietary software is always bad. I have created many closed source applications myself. But these systems are better as addon components or for tasks that require special and unique proprietary technology, not to hold and process your core data. The risk that your data will be held hostage and that you will have to pay inflated prices for continued proper access is too high. 

You can add clauses to contracts to try to keep access rights to your data however this ignores technological limitations. Information and data complexity is a fundamental, even mathematical, property of software systems. It is nearly impossible to make independent and closed systems data formats compatible with each others in changing and evolving applications. At the very least, if you have to migrate to a different system, you will have high costs, a difficult transition period and a situation where you will require help from the company you are leaving which will have no incentives make things easier in your departure.

There are better alternatives. Some people have suggested allowing multiple EMR systems and thus some competition which is certainly an improvement over a monopoly. However, even better, some type of systems are developed under the “open source” model. This means that companies working on the system are required to make public the source code used to build the system. It means multiple companies can work on the system, improve it and compete on offering support and services for it. Developers usually cooperate publicly on forums as you can see here (http://oscarmcmaster.16.x6.nabble.com/) for the Oscar EMR used by thousands of doctors accross the country.

I was recently part of the implantation of Oscar EMR in a new clinic in Moncton for five doctors. The installation was easy and took less than a day, the cost for support is about $100 month per doctor and I estimated that our 5 year cost for the clinic will be about $30 000. Had we signed up for the Intrahealth system, in the same time frame we would have paid $40 000 upfront, $120 000 in monthly fees and the government would have put up $80 000 for a total of $240 000 or 8 times the price of our current, more open and more compatible and in my opinion more future proof system.  You can clearly see the effect that competition amongst multiple companies has on price.

Sure you can find vendors charging high prices but that is usually because they already have a large user base locked-in their legacy system and they wouldn’t want to set a lower price precedent for these users.

Here are some important questions that need answers:

Has NBMS properly evaluated the risk of letting a single private company’s closed software, Intrahealth, control every New-Brunswicker’s medical record?

If the exclusivity contract was necessary to lower prices, why is the price 8 times that of a competing, leading edge system? Shouldn’t the price be lower not higher?

If it is so difficult and costly to make multiple systems connect to hospital data, why did Velante have to contractually forbid others from this connectivity to prevent it? I personally talked to developers and got very reasonable prices to do the work, a few tens of thousands of dollars, lower than the price difference between just a few installation of Intrahealth and Oscar. It’s not as if you have to provide different connection protocols for each system. You only need to provide a single type of connection based on the secure standards defined by Canada Health Infoway and make it the responsibility of the different EMRs to adhere to this standard. The standardization work on this communication channel has already been performed by other provinces.

Why has Velante been trying to push our small clinic into a $240 000 system when we were able to get a better one for $30 000?

Common courtesy…

colleagues

Prior to enrolling in medical school, I had thought of medicine as a noble calling.  An honourable profession characterized by scientific certainty, propriety, decency, concern for others, long hours, self-sacrifice, and hard work.   The doctors I read about were exemplary human beings.   This view was certainly bolstered by being a childhood patient of Dr. Lee Stickles, Fredericton’s iconic and beloved pediatrician.  Inspired by his easy-going patience and professionalism, I had medicine on my mind when I started at UNB in the fall of 1975.

It wasn’t that easy.   Though capable of making good grades, I had difficulty settling down to work in the new environment.   So many interesting people and things to do.   I gravitated to the campus radio station, immersing myself in the music and technology of the broadcasting business.   I spent too much time doing things that, though fun at the time, were not leading me down the path to medical school acceptance.

It was only years later, having gained some important work experience and perspective on life that I returned to UNB with a new outlook and a plan.   I made the marks required to be accepted to medical school, and I never looked back.

We as physicians, tend to support one another.   The Hippocratic Oath exhorts us to respect out teachers.  We support our colleagues.  It comes, I believe, from the common bond we share.   The bond of dedication to our patients, the desire to promote health and fight disease, and to try to leave the world, when all is said and done, in better shape than we found it.  One of my biology professors told me before I left for Halifax that medical school, in terms of rigidity of discipline, was second only to Marine Corps training.   He was right.   It was four years of unending study, long hours,  intense exposure to human suffering, poor sleep, hasty meals, and exam after exam after exam.   It’s the kind of environment where you develop friendships that last a lifetime, with people you know you can trust with your life.

I trust my physician colleagues in the New Brunswick Medical Society.

I know that the President of the NBMS respects the wishes of the membership and will do all that she can to implement the resolutions of September’s Annual General Meeting, including the one that I put forth.  My resolution directed that the NBMS not impede non-Velante EMR users in their quest to improve the capabilities of the systems they have implemented at their own expense and used for years.

What ought to be done, what MUST be done, is for the President of the NBMS to make a sincere, written request to the Minister of Health to amend the Data Sharing Agreement of June 2013 to allow for multiple EMR vendors.  It must be the President who does this.   This task cannot be delegated.   It cannot be mumbled or muttered in a half-hearted way, and the request cannot be dropped at the first sign of resistance.   To fall short of this – to ignore the wishes of the membership – brings discredit and disrepute to the Society, and shame to the medical profession.