HIE, SaaS and Low-Cost, Nationwide Adoption of EHRs

by | Feb 6, 2009

doctorsnhspubdombigThe Stimulus packages (HITECH Act) that are winding their way through the Senate and House call for spending some $20B on healthcare IT initiatives, the lion’s share to provide incentives to physicians to adopt “certified EHRs”.  In addition to the very real potential that this legislation will completely shut-down HIT innovation, another issue was brought to our attention by one of the leading Health Information Exchange (HIE) vendors – getting an EHR into every physician’s office could be done for about a tenth of the cost.

So how would they do it?

Using their Software as a Service (SaaS) solution the HIE vendor would:

Establish 200 HIE/RHIOs nationwide that would connect to…

  • 6,250 hospitals
  • 100 national and regional reference labs
  • 660,000 physicians.  Among those physicians, 550,000 (their estimate) would have access, in addition to  network node, access to a lightweight EMR on the network.

Cost of software: $500M/yr

Their is also the cost of operating an HIE, which in their experience is about 2:1 operating costs to software/service cost.

Cost of operations: $1B/yr

Total Cost: $1.5B/yr to provide a National Health Information Network (NHIN) and insuring all physicians have an EMR.

Roughly 7.5% of what is proposed in the economic stimulus package for HIT.

Granted, these numbers come from a vendor and maybe slanted (though we believe they are well within reason) and these are annual costs, not the one time costs that the legislation is based upon, but those are small quibbles.

What is important here are the following points:

Current stimulus legislation would not likely support an “EMR lite” solution as it is unlikely such an EMR would meet “certified” status.  Besides, do all physicians really need a full blown, “certifed EHR”?

Proposed spending on HIT is huge and if dumped into the market too fast, besides being wasteful, could make the situation worse.

Legislation, and its support (via incentives) for only “certified EHRs” will not solve the problem of secure, health data liquidity.  IT takes far more than simply adopting a piece of technology to make all of this work.

In closing, below are some comments provided to us by a physician who is currently using a highly regarded CCHIT-certifed EHR. His/her comments clearly show that being certified does not mean delivering end user value.

I have used about 6-7 EMR’s, and I will say that VendorX (editor’s note: name masked by Chilmark) is probably the best, but that’s not saying much. In the kindgom of the dead, the PEA (pulseless electrical activity) patient is king. VendorX is a PEA. I think that they benefitted most from a very charming PR campaign, but when you peel back the propaganda and notice that while you are billing almost every visit as a 4 or 5, but you have to pay for IT, more staff to handle the onerous data entry, and you yourself have a day that is 1-2 hours longer, it becomes a zero to negative sum game.

I think people’s knee jerk reaction to EMR’s has to do with “it’s a computer, therefore it has to be better”. But healthcare is not as easy as stocking shelves or tracking inventories. You have to deal with people, and the fact that taking care or patients while using one of these EMR’s is as distracting as trying to drive with two wasps buzzing around the car.

That and the fact that the EMR’s don’t talk to each other is another serious issue, so I have to scan all the specialists’/hospital records in and manually enter the data.


  1. David Harlow

    Interesting proposal. Raises a couple of questions for me:

    1. What about the cost of re-engineering the legacy workflow? My understanding is that this was a significant issue for providers participating in the MAeHC experiment.

    2. If systems are not CCHIT-certified, don’t we run the risk of creating a series of islands rather than an interoperable whole? (Real question, not rhetorical.)

    3. Long term commitment to funding (not unique to this proposal).

  2. Dr. Gerry Higgins

    I don’t know who this vendor is, or where they got their information, but it is incorrect. Having been just up on the hill, and working with our own EHR system, your data are wrong.

    First, the current EHR vendors will lose market dominance to Microsoft’s Amlaga platform.

    Second, the EHR stimulus has been drastically cut through Republican intervention, and now represents less than 20% of that $20B figure.

    Third, there are well documented and highly significant cost savings associated with adoption of the EHR – your audience should read the valid scientific literature before making inane and self-serving comments without understanding health infarstructure.

  3. John

    David, in answer to your questions:
    1) Workflow is always an issue with any IT/technology deployment. Yes, there will be costs associated with that but those costs are virtually impossible to pin down as there is such high variability. In the case of lightweight EMR solutions, workflow costs should not be too high as such a solution is targeted at basic ambulatory practices/activities in small practices.

    2) Not a big fan of certification processes such as CCHIT as that is rarely the problem with interoperability, which is a problem more related to policy and actual technology deployment. Rather than certification, how about incentives for sharing records, incentives that go directly to physician/practice. If such occurred, physicians would adopt solutions that supported such without any need for some form of certification.

    3) Long-term commitment… That’s a tricky one, though it has been demonstrated by some HIEs that you can actually make them self-sustaining. Adopt their best practice models may lead to a self-sustaining model for the entire system.

    Dr. Higgins,
    1) As you are from Medstar, which was the IDN that created Amalga (Azyxxi) in the first place, not too surprised by your strong promotion of the Amalga platform. Yes, it is an excellent platform, yes its adoption may lead to a decrease in market dominance of large EMR vendors, but no, Amalga will not play much of a role in small ambulatory practices which is where we have the biggest issue with lack of EMR adoption. Thus, this HIE vendor offering an SaaS lightweight EMR does offer an interesting approach to achieve widespread adoption of HIT.

    2) The latest news we have seen (at least as of mid-morning today) still has that $20B in the Stimulus package for HITECH Act. You are in DC so maybe you have a more accurate pulse, but as of the time of posting this piece, $20B was a good number.

    3) Sure, there are plenty of well-documented studies on EMR adoption and savings, we understand that and fully support programs that will increase EMR adoption. But in he end an EMR is but a tool and if you give a sledge hammer to someone who really needs a light hammer for finish carpentry, well you end up with a mess. There are an equal number of reports, articles, studies that also show just how bad it can get in poor deployment of HIT.

  4. Alex Burgess

    Way to go John!!! Great catch regarding Dr Higgins’ advocacy.

    My company and I are watching the latest developments in Congress with interest/concern/optimism, and despite the lobbying muscle the legacy EMR vendors (no need to name) have, I am impressed by my boss (please see Dr John Haughton’s review of the pending stimulus bill on the Healthcare Blog – http://www.thehealthcareblog.com/the_health_care_blog/2009/02/stimulus-bill-offers-docs-big-incentives-for-technology-but-demand-effective-use-.html) and other internet-oriented HIT company CEO/Founders’ ability to reach Congressional staffers/leadership and help them understand the difference between “certification” and “efficacy/cost-effectiveness.” Perhaps we should raise our prices through the roof as they have and convince our customers they HAVE TO pay that much to join the “21st century” but then again, I probably couldn’t live with myself.

    To David’s question #2; CCHIT, among MANY other positive and NEGATIVE components, does NOTHING to mandate SEMANTIC interoperability among applications which is critical to exchanging clinical data in a meaningful and relevant way. We work with CCHIT certified EMRs EVERY DAY trying to get them to talk to each other and they simply were not designed to share population-based clinical data in any kind of way. CCHIT, like “certified-EMRs,” is a red herring and something easy for a politician or media personality to grasp and regurgitate.

    If any media personalities are reading this column, please continue to review Chilmark’s blog and particularly “John’s” comments… These folks are tracking towards pragmatic solutions to our national health challenges. If companies like mine and others can create truly open platforms that respect our customers’ (and their patients’/customers’) needs, then MAYBE we might be able to create a truly interoperable collection of HIT tools that don’t require “INFRASTRUCTURE” to support or billions of dollars to build. The applications themselves should provide the infrastructure through web services and other rapidly evolving technologies. Don’t write stories compelling folks to spend more money than they need to or have in their accounts.

    Thanks everyone for the great comments!




  1. ICMCC Website - Articles » Blog Archive » HIE, SaaS and Low-Cost, Nationwide Adoption of EHRs - [...] getting an EHR into every physician’s office could be done for about a tenth of the cost.” Article John…
  2. Tethers, Pipes and Cloud | symtym - [...] Health Records the other day and working my way through the text. Also read an excellent post by John…
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