Site Bugs and Improvements

[drbowen]

Brady,

The list I gave several posts above is not intended to be all there is on this bullet points. The ROI discussion is really an entire topic that deserves its own article. ROI presumes accurate cost data but this cost data frequently has to be estimated. These estimations need to be modified based on specific practice associated costs. This makes as ROI very subjective and it is easy for a large vendor to make assumptions that may not be very accurate when it comes to a small practice. We wanted to follow this up with a more extensive article to explain these assumptions and how we arrived at "372 percent".

Sam Bowen, MD

[brady]

Hi Sam,

Regarding your revised article, have the following feedback:
1. Change everything to third person and use "you" instead of "I". Currently a bit confusing with the mismatching of first and third person.
2. The list of eleven items makes me yawn and want to go somewhere else. I'm much more engaged when reading the topics below this.
3. The paragraph before the list of eleven items could get a highlighted label before it with something that quickly illustrates what your saying there (I think this paragraph explains an important concept, but having a highlighted first sentence quickly describing it will fit it into the article better and keep me engaged; perhaps something like "How can Open Source EMR's provide all these things?" to tie in with the stuff above).
4. The ROI stuff should probably go to the bottom unless you have some sort of illustrative example
5. Aren't recividism and acceptance by practitioners the same thing: if so would go with acceptance by practitioners and yank the recividism stuff (as an aside, I think you went opposite in the section when stating 17% of practitioners hate their software; shouldn't this be 83%?) Or could combine label "Acceptance by Practitioners (Recividism)".
6. The "What you really would like to see is a web enabled EHR that can be managed centrally." seems out of place since this can be accomplished by both proporietary and open source (i like the paragraph above it; perhaps end it with that open source, specifically openemr will not have this issue)

This thing is looking really good. After some more polishing, will nicely argue for open source emr's while also educating the reader on some important concepts that differentiate open source from proprietary with nice engaging examples.

-brady

[jcahn]

Ahoy Sam,

Good document. I agree with Brady on these things:

Skip the list and just go with the explanatory paragraphs.

I too am confused about the acceptance and recidivism numbers. I think the acceptance rate is a clearer concept for docs and a reference here would go a long way to add credibility to an incredible statistic.

ROI (and the math) needs to be a separate blog.

Thanks, Jack

[drbowen]

Brady, Jack:

I appreciate your comments. It is a work in progress for sure.

I was worried about the length myself. We could use the links to point to individual articles so that the whole article doesn't become too long. I will be working on the ROI paragraph soon. It's just harder to take a spread sheet for what is an inherently a mathematical equation and turn it into prose.

If you guys have specific statements or paragraphs I would love to have you type them up. I would be far easier for my to cut and paste and then edit to smooth things out.

I have not changed the whole article to either 1st person or 3rd person yet. Much of this is better in third person. The first paragraph is literally from my own personal experience and it is harder for me to detach this and make it third person because of my own emotional pain over this.

Acceptance and recidivism are related but are clearly not the same. The Acceptance is quite literally how many practitioners really vote "yes it was a good move" to a new program. It is a measure of how many strong proponent that would make a good reference for the program. Recidivism means how many organizations elect to burn their entire investment which literally can run several hundred thousands to several hundred millions and choose to no longer use the program, delete it from their servers and completely replace the program with something else at great expense and hardship to the organization. A recidivism rate of 17% is a pretty shocking number if one starts to consider the underlying investment involved. I think most stores and sales organizations would likely not be able to stay in business with this type of number. How would GM be doing if 17% of the new car purchasers brought their car back, dropped the car and keys off, and walked on foot to the nearest Ford dealership?

Sam Bowen, MD
http://www.oemr.org

[jcahn]

Actually the car analogy came to my mind also, but as a way to explain vendor lock-in: Would you buy a car if you had to take it to only one dealer for service or the car would stop running? This is the type of contract some doctors are looking at with their EMR choice. I think it might be good to have that more detailed explanation in the paragraphs, and even the automotive analogy.

[brady]

Hi,

Still a bit confusing regarding the acceptance and recividism; appears they are actually opposite to each other and appears the recidivism rate of 17% is not as impressive then (since this is saying 17% of clinics basically walk away from the EMR); the acceptance rate of only 17% is impressive, though. I'd suggest just focusing on acceptance then and avoiding this confusion brought on by recidivism (also, note that the definition of recidivism is "repeated or habitual relapse, as into crime." which is kind of odd ).

You could also eliminate ROI for now, and you'd still have a strong article.

Not too concerned with length, since the descriptions you are providing are engaging and it's organized well (a reader can quickly scan to subject/concepts they want to read about).

-brady

[drbowen]

I am aware of the use of the word recidivism in the legal system and maybe I am using the wrong word. Throwing away a $250K investment as totally worthless,turning around and spending $375K on a new program to replace the other one. This is a type of buyers remorse that is the equivalent of spending $675K plus having to cost retrain the staff twice, loss of productivity of the practitioners twice. Phillip Longman compares VistA to some proprietary examples in this article.

Longman P. Code Red, how software companies could screw up Obama's health care reform. Washington Monthly July/August 2009.

http://www.washingtonmonthly.com/featur ... ngman.html?

"Things did not go so smoothly at Children’s Hospital of Pittsburgh, which installed a computerized health system in 2002. Rather than a godsend, the new system turned out to be a disaster, largely because it made it harder for the doctors and nurses to do their jobs in emergency situations. The computer interface, for example, forced doctors to click a mouse ten times to make a simple order. Even when everything worked, a process that once took seconds now took minutes—an enormous difference in an emergency-room environment. The slowdown meant that two doctors were needed to attend to a child in extremis, one to deliver care and the other to work the computer. Nurses also spent less time with patients and more time staring at computer screens. In an emergency, they couldn’t just grab a medication from a nearby dispensary as before—now they had to follow the cumbersome protocols demanded by the computer system. According to a study conducted by the hospital and published in the journal Pediatrics, mortality rates for one vulnerable patient population—those brought by emergency transport from other facilities—more than doubled, from 2.8 percent before the installation to almost 6.6 percent afterward. "

"Among the most notorious examples is Cedars-Sinai Medical Center, in Los Angeles, which in 2003 tore out a "state-of-the-art" $34 million proprietary system after doctors rebelled and refused to use it."

"According to Dr. Scott Shreeve, who is involved in the VistA installations in West Virginia and elsewhere, installing a proprietary system like Epic costs ten times as much as VistA and takes at least three times as long—and that’s if everything goes smoothly, which is often not the case. In 2004, Sutter Health committed $154 million to implementing electronic medical records in all the twenty-seven hospitals it operated in Northern California using Epic software. The project was supposed to be finished by 2006, but things didn’t work out as planned. Sutter pulled the plug on the project in May of this year, having completed only one installation and facing remaining cost estimates of $1 billion for finishing the project. In a letter to employees, Sutter executives explained that they could no long afford to fund employee pensions and also continue with the Epic buildout."

Throwing away a $154 million dollar investment is a dramatically different statement than a lukewarm acceptance rate of less than 50%.

The definition of "recidivism" that I found states: a tendency to relapse into a previous condition or mode of behavior; especially: relapse into criminal behavior .

While this term is most commonly used to describe relapse into criminal behavior my understanding is that it is the technical word to be used to describe buyer's remorse when a consumer takes a product back for exchange or refund. If this is not the correct word, what word should I be using for the 17% of practice managers who are willing to throw away hundreds of thousands, or hundreds of millions, of dollars, because the software is so bad or completing implementation will bankrupt the facility?

Sam Bowen, MD

[drbowen]

An average practice selecting a high end program spends about $50,000 per doctor. In a 5 doctor practice a product like "Centicity" would cost approximately $250,000 for the Software licensing and training expenses. The loss of productivity of the physicians is about 10-20% over the first six months. 5 x $400,000 each x 10% = $200,000. Ongoing user monthly maintenance, maybe $5,000 per month x 12 = $60,000. The approximate cost of adopting this EHR is $510,000. Now lets say the doctors totally rebel and insist on changing to Cerner instead. This costs another $250,000 + $200,000 loss of productivity, plus $60,000 maintenance fees. After the dust settles the practice has spent $1,020,000 on adopting Cerner.

Recidivism is also used in reference to rehospitalization for Medicare patients:

Healing Medicare Hospital Recidivism: Causes and Cures. Ann Marie Marciarille, American Journal of Law & Medicine, 37 (2011): 41-80
, © 2011 American Society of Law, Medicine & Ethics, Boston University School of Law.

Recidivism is used to describe students dropping out of school.

The Free Online Dictionary: Recidivism (; from recidive + ism, from Latin recidivus "recurring", from re- "back" + cado "I fall") is the act of a person repeating an undesirable behavior after they have either experienced negative consequences of that behavior, or have been treated or trained to extinguish that behavior.

Wikipedia offers a suspiciously similar definition: Recidivism (play /rɨˈsɪdɨvɪzəm/; from recidive + ism, from Latin recidīvus "recurring", from re- "back" + cadō "I fall") is the act of a person repeating an undesirable behavior after they have either experienced negative consequences of that behavior, or have been treated or trained to extinguish that behavior. It is also known as the percentage of former prisoners who are rearrested.[1]

Most commonly the word is used to describe repeat legal offenders that get incarcerated repeatedly, child abuse / child neglect that require repeated interventions by child protective services and in medicine it usually refers to rehospitalization. This is commonly used to express relapse rates in drug and alcohol addiction after prior efforts at treatment. It also refers to recurrent injury rates in alcoholism but in the article above it refers to the societal expense of any rehospitalization.

The reference is to fall back to a previous behavior after having already experienced prior negative consequences. I in previous software articles where the word "recidivism" is used to mean falling back to the prior administrative procedures, either paper records, a prior EHR, or purchasing yet another EHR. It is a type of "Buyer's remorse" when there consequences are especially negative.

So let me know if you can find a better word to use. In any case this decision to change the previously accepted software has very severe consequences.

Sam Bowen, MD

[brady]

Hi Sam,

Would probably combine the Acceptance by practitioners and Recidivism into something like:

Acceptance by practitioners - Current large vendor products have about 17-50% acceptance, meaning less than half of practices are happy with their choice in proprietary EMRs. In fact, 17% of practices hate their chosen proprietary EMR so much that they throw it into the digital scrapheap and go through the pain and additional costs of selecting a new product and starting the pain all over again.There is a poll on the OpenEMR development site that is indicates an acceptance rate of 92%. Why is this so different? The commercial vendors should not be very proud of these numbers.

I'm a bit cynical of the 92% rate poll quoted here, either should provide the link to the poll or state this fact less strongly or remove this statement.

-brady

[Aethelwulffe]

OK,
Here we go again.
I'm talking about pitch code. That is the sequence in which you approach a subject that draws the listener in. It is a standard for not pinging hot buttons before they should be pressed, and punching them after the relevant comparisons have been made and the "stage is set". Brady has tried to dismiss my posts, and has indicated that he wanted to hear specifics in Jack's post that I am referring to...obviously we are not on the same subject, or just an contrariety competition is going on. I am just saying that while editorials by "non-experts" may use any approach they like, advertizing/promotions have to be very carefully designed.

That junk I will leave behind. It was offered as advice for those who may wish to hear it.

On the "Who hates what"....

Who are commonly the decisions makers in a medical practice? While in small clinics, it is the doctor/president/ceo certainly. Often instead it is a practice manager or a IT guy who says "I can give you this." Just as often, it is not really the doctor, practice manager, or IT guy who makes the final decision. It is the professional decision maker: i.e. the slick salesman who gets the foot in the door. I feel that to promote a product, and organization, or a concept, we have to start being realistic about demographics. Male doctors will make decisions differently from female doctors. IT guys will have different criteria from doctors. Practice managers (good ones) will make decisions based on what most closely pleases the clinicians, the front desk, and that irritating IT guy all at once. Bad/ignorant/underpaid practice managers will go with what seems easiest on themselves.
Let's suppose you have always made your EMR pitch to a doctor, probably male. Are you sure you know how the pitch should be made to the pushy Latina billing lady who will complain until she gets what she wants? Are you sure you really know who the organization as a whole sells to? I think that a government health authority will require a different approach than an aging doctor. Obviously, pitching OEMR itself is a different than talking about OpenEMR.
Just make sure you are not pigeon-holing when you decide on the front face of the organization itself. How sure are you guys about your demographics paradigm?

I think that OEMR should represent itself as an organization finding solutions for the medical community. AFTER convincing folks that: 1. We are real and in it for others. 2. We know what we are talking about (I add personal disclaimer here). Then we present the solutions (open source software, Open Source communities) to the user.