Never before has the ambulatory EHR landscape been of such importance to the acute-care CIO. With the relaxation of Stark a few years ago, some savvy health systems began underwriting EMRs to independent practice in their areas. While HITECH threw the market a curve ball that temporarily slowed the Stark snowball, it has recently picked up apace. Most now realize that integrating with local physicians, and the guaranteed patient flow they constitute, is all-important to maintaining a robust market presence in the coming decades. To learn more about how HITECH and Stark are effecting ambulatory EHR vendors, HCI Editor-in-Chief Anthony Guerra caught up with NextGen Healthcare Information Systems President Pat Cline.
GUERRA: Overall, how has HITECH changed the market? Are we seeing the sales that people thought or is it still little slower than you anticipated at this point?
CLINE: I think it’s a little bit slower than everyone in our business anticipated. I think when the legislation was signed, it caused the opposite effect of what was intended. It was obviously designed to increase adoption and stimulate purchasing and implementation of electronic health record systems, but given that a lot of the definitions – for example, meaningful use and certification –weren’t clear, it had the effect of freezing or slowing down the marketplace.
But I think, through the summertime, as companies like NextGen Healthcare and many of our competitors educated or helped educate the marketplace, people got more comfortable that meaningful use, in fact, would be achievable, that the certification process wouldn’t be too far from the current certification process. Certainly, the criteria might be different, the standards or the procedures for certification might differ, but I think the market, as information has gotten disseminated, has gotten more comfortable.
So I think we’re seeing an increasingly robust market. I wouldn’t say it’s completely thawed, and I would say that there are still many practices waiting for clarity, but certainly – and more so on the high end – we see more activity. So I think the worst is behind us and we’ll see, in my opinion, an increasingly robust market through 2010.
GUERRA: I’ve been a fairly outspoken critic of the legislation. What’s your take?
CLINE: Obviously, it’s a very, very complex issue and therefore the legislation needs a lot of detail. I think those that opened the box had no idea when they started what would ultimately be inside, though I do think that the details are important. So you couldn’t just start paying doctors for using electronic health record systems, for example, without defining what an electronic health record system is and what it should do and how it would be used, and so many other things. And we’re just starting to see a lot of related things, some of which have been addressed in the past, for example, privacy and security and how they’re to be dealt with, and things like tying these systems together, for example.
It’s one thing to say that, as far as meaningful use goes, systems will be interoperable, but what specifically does that mean, interoperable with what? Does that mean with patients, does that mean with other providers, does it mean with large health systems, does it mean the state health information exchange, the national health information network or some analog to it – and all of these things, as time goes on, have come up, and ultimately the marketplace and the providers need answers.
GUERRA: Even if HITECH solved the financing problem for providers, change management is still the hardest part, and not much has been done to help with that. It seems the regional extension centers won’t be running until it’s too late. What are your thoughts?
CLINE: First, that’s a terrific question. Both, in my opinion, are critical. You can’t get to the change management issue unless you can get past the financial issue. For many practices, especially the smaller practices, the financial barrier was too difficult for them to get past. I think when the financial barrier is knocked down, or becomes less of an impediment, a critical issue is the change management. Companies like NextGen, I think, have gone a long way to streamline our implementation processes and do more heavy lifting for medical practices and make systems easier for them to use. We’ve made it easier for them to learn to use the systems by opening, for example, training centers across the country and delivering robust computer-based training and Internet-based training – all of those things are critical.
Hopefully, the regional extension centers will play a part, if that’s the way that we ultimately go, and I think many other third-party organizations will play a part. I think the biggest part of the job is to be done by the vendors and that is, again, making their system easy to implement and easy to use.
GUERRA: As a vendor, where do you draw the line between what you can do for a customer and what they must call in a consultant for?
CLINE: I think it varies by size and type of customer. Most of our implementations are done without consultants on either side. When you get to the very large enterprise deals, and NextGen does a lot of business in that space, you typically do see consultants involved in the rollout. We execute a number of very large, typically multi-million dollar transactions every quarter, and in all of those cases, there is a large health system or an IPA that is purchasing a number of licenses to roll out to smaller groups. They might have a one or two year rollout plan, and they might have hundreds of medical practices to bring live on our solution. Those are the ones that would typically reach out to third parties.
GUERRA: It seems much of your business is going through the hospitals, rather than practices buying direct. Is that accurate?
CLINE: We see, I think, as our competitors see, large health systems continuing to take advantage of the relaxation in the Stark regulations. There have been some health systems who have either slowed down or lessened their contribution based on either the economy or HITECH or some combination of the two, but we do see continued Stark-related spending.
Hospitals are continually looking to either increase or preserve their referral stream and that means solidifying relationships with as many physicians in the community as possible, and they find that any way they can add value, bring value to the practices in the community, tends to be positive for the organization. So many of them, of course, have found that by bringing IT and IT services – whether it’s implementation help or financial help in purchasing, or interoperability that makes practices more efficient, or some of the consulting that you mentioned, hosting types of things, interfaces to critical hospital systems – are all terrific ways of adding value.
GUERRA: Obviously they think it’s in their long-term interests to spend that money. Do you agree this is a critically important strategy for a health system going forward?
CLINE: I do. Certainly, there are millions and millions of dollars being spent, and then there are more millions and millions of dollars at stake, especially in a competitive market. If hospital A locks up most of the physicians in the community through these value-added services, hospital B is going to have, I believe, an increasingly difficult time surviving.
GUERRA: Because doctors will certainly prefer to send patients where they can view their status, discharge summary, etc.
CLINE: That’s right. I think it’s less about who purchased the EHR, though there may be some residual affinity based upon that. I think it has to do with what’s more convenient and efficient for the medical practice. As a physician, through the normal workflow as I’m seeing the patient, it’s easy for me to click on a couple of buttons or checkboxes or quickly annotate something that sends all the information that might be required to Hospital A. But to make a referral to Hospital B, I have to put down my EHR and fill out forms or go on to the Internet or something like that. I’m going to make those couple of extra clicks, especially if I know that when that patient is treated in Hospital A, the quality information is flowing both ways, the results are there. I can make, for example, changes to orders using a CPOE system. It’s, again, part of my normal workflow as opposed to a lot of added work for me or somebody in my practice. I’m going to want to send my patients to Hospital A.
GUERRA: Let’s talk about your relationships with the major inpatient vendors. Are they all about equal or do some play nicer than others?
CLINE: I think we have reasonable relationships with all of them and I think, by and large, the acute care vendors recognize the need for and the demand for interoperability. We do have more meaningful integration with the Siemens’ products. Siemens is a partner of ours and we have many Siemens customers as NextGen customers, but we also interface and exchange data with just about all of the other ones. There are a couple of both ambulatory and acute care vendors who have more of a closed system and are a little bit more closed-minded, but when push comes to shove, they’ll typically extend an interface or allow interoperability for the good of the customer.
GUERRA: And I’m guessing you’re not interested in naming those you’re calling out?
CLINE: I think it’s a little more difficult to interface to Epic and Meditech than with many others, but again, when push comes to shove, we’re able to get at that.
GUERRA: And do you think that’s a company philosophy, or is it more of a technology-integration problem because of the way those systems are structured?
CLINE: I think it’s more of a philosophy. I’ve got to believe that those companies are technically astute, based on what they’ve accomplished to date, so I don’t think it’s a technology issue. I believe it’s a desire to have their customers think twice about purchasing other vendors’ solutions and look real hard at their respected solutions prior to doing so.
GUERRA: But Meditech doesn’t even have much of an ambulatory EHR. I mean, no one speaks of that in glowing terms.
CLINE: I’m not going to disagree with that. That’s why Meditech and NextGen Healthcare have a number of customers in common.
GUERRA: And do you have any customers with Epic in common?
CLINE: We have two so far.