Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, April 10, 2014


I got an email from a company called, Software Advice, that provides free recommendations to anyone interested in adopting a new business software system. The company's income source seems to be the software vendors:

Software Advice is 100% free for software buyers. We get paid when we make a good match between a software buyer and a software vendor.

Anyway, the email asked me to take a look at their report, entitled, Mental Health Meaningful Use Market Share IndustryView | 2014. There's also a nice slideshow:

Mental Health EHR Market | MU Attestations from Software Advice

Before I comment on the report, let me answer a question: Why am I writing this? Because I thought it was interesting, because they asked nicely, because the report is well-written and gives due consideration to its limitations. NOT because I'm promoting the company-I guess I'm okay with it if they get more business as a result, but you can take it or leave it, and I certainly have no intention of finding a vendor through them, especially since I already have a free EMR system that I don't use. And NOT because I'm getting paid to do so-I'm not.

There. I said it.

The report looks at the number of providers in psychiatry attesting to meaningful use of an EHR system, and compares 2012 to 2013 results, which were recently released by the CMS.

I haven't written about meaningful use, largely because I'm not a medicare provider, so I'm not affected by it. Briefly, providers (also hospitals) who incorporate an EHR in their practices are eligible for incentives to help cover the cost of implementing the EHR. In order to receive these incentives, they have to demonstrate "meaningful use", which has 3 separate stages and numerous "quality assessment" requirements, see the link if you really want to know the details. In addition, starting in 2015, medicare providers who do not demonstrate meaningful use will receive payment deductions in their medicare reimbursement.

The report also found that the number of Mental Health EHR vendors increased from 2012 to 2013.

This is where things start to get interesting, because it's expected that in the not-too-distant future, there will be consolidation of EHR vendors. There are now too many platforms to be sustainable, many providers are dissatisfied with their current systems, incentive money is drying up, so the bigger fish will buy out the smaller fish, or the smaller fish will just go belly-up.
There's also the issue of interoperability. Say a physician in private practice uses one EHR system, but the hospital he's affiliated with uses another. At some point, these two systems are going to have to share information about common patients, so how do they do that? In all likelihood, the EHR systems that will win out will be the ones with the most flexibility, that can facilitate connections with other systems.

It'll be like Kindle vs. Nook, or VHS vs. Beta, or Cassette vs. 8-track.

So the question is, why were there more Mental Health EHR Vendors in 2013 than there were in 2012?

One reason may have to do with one of the limitations of the report (I'm not getting into most of them, but it's not a long document, and it delineates many of its own shortcomings, so you can check it out for yourselves). There are plenty of psychiatrists who don't accept medicare, and who are, therefore, not interested in any meaningful use attestations, and whose use wouldn't be accounted for.
Also, most EHR's aren't very user-friendly for clinicians. They seem to be designed mainly for billing purposes, which leaves out the real function of a patient record. Could vendors be expanding in the hope of tweaking their systems to be more usable, and wanting to be on the forefront, testing their systems with those who are interested in meaningful use qualification, but really aiming for a larger audience, including non-medicare providers?
Or are they expanding so they can take advantage of the surge in meaningful use providers, with a plan to consolidate once that bubble bursts?

And speaking of notes. The following is the transcript of a 2 page note written, by hand, in 1981. The patient was a relative of mine, now long dead, so this is not a confidentiality violation. I found the chart in a bunch of old papers I was going through. The note is a consultation by a "Radiation Therapy Attending", and it's the real reason I was interested in writing a post about electronic note systems. I'd like to see an EHR spit this out:

52 white male with soft tissue sarcoma R distal thigh. This presented as a painless lump~early 4/81. Needle Bx was nonDxic. Incis Bx 5/22/81 shows a high grade pleomorphic sarcoma, ? rhabdo. Subsequent studies include normal counts, SMA 6/12, bone and liver scans. CXR 5/21/81 showed a 1.1 cm RUL lung nodule, new since CXR of 1/81. This was confirmed by tomog, which also showed a 1 cm LLL nodule; both appear to be mets. (- PPD, no Hx lung disease, cigs 1 ppd x 20y). CT scan of thigh 5/27 showed ~ 10 cm nonenhancing lesion without evidence of bone or vascular invasion. Arteriogram  today showed an 11 x 6 cm highly vascular mass beginning just proximal to R medial condyle; scalloping of popliteal A could represent tumor encroachment.

PE: Well appearing man in NAD, alert, oriented, normal neuro, heart, lung, abdomen, testes. Extrem WNL except firm 9 x 9 cm mass R distal medial thigh with healing 5 cm incision. Mass blends into underlying M of vastos medialis and extends 3 cm distal to incision (just prox to medial condyle) and 1 cm prox to incision, 2 cm post-lat to incision and 9 cm (circumferentially) medial to incision, being just medial to midline. There is a soft 1 cm R inguinal node ? (I can't read this word), no popliteal or other adenopathy. Pulses, M strength, joint function are all good.

Assess: Pleomorphic sarcoma R thigh, G3T2N0M1. LAG pending (was + in 66-89% of children with extremity rhabdo).

Recommend: Begin with chemoRx to try to eliminate micromets and evaluate response of primary, nodes and lung nodules (Children with rhabdo often get good response to VAC-eg Intergroup/Rhabdo Study, Maurer et al, Cancer 40:2015-2026, 1977 had 50% CR and 30% PR, some still in CR at 1y, few at 2y. Also Harvard: Dritschilo et al, Cancer 42:1192-1203, 1978, VAC and lung RT and primary RT +/- conservative surgery, 96% local control. Adults (variety of soft tissue sarcomas) have had 10-12% CR and 45% PR with adria-DTIC +/- CTX and VCR or adria-methyl-CCNU--both SWOG studies, Benjamin et al. pp. 309-315 in Management of Primary Bone and Soft Tissue Sarcomas, year Book, 1977, and Rivkin et al, Cancer 46:446-451, 1980.)(boldface mine)

If he responds well to chemoRx, suggest conservative surgery of R thigh and RT~ 5000 rads R medial thigh from knee to groin +/- iliacs (depending on LAG) and boost of primary to ~6000-6500 rads. Would also consider low-dose whole lung RT ~ 1500 rads/ (can't read) and boost to nodules. If he progresses on chemoRx, then palliative RT +/- chemoRx. Would like to reevaluate in 3-6 weeks. 

Let me reiterate, this was a hand-written note, including all the citations. I've never seen a note like this in any chart I looked at throughout my training. If Software Advice can find me an EHR that can generate this, then I WILL do business with them. But I think the days when a consultant would write this kind of note are long gone. And really, the key isn't the note, it's the doctor who wrote it. 

1 comment:

  1. Couldn't agree more - the brilliant hand written note with references is a site to behold. I worked with Cardiologist whose notes were fine English literature and he could put them in the EHR. That is extremely rare. The usual print out from the massive enterprise wide EHR with the annual licensing fee of tens of millions of dollars is several hundred pages long. Most of the pages contain no useful information. It is rare to find a discharge date for example. It is rare to find an actual ECG tracing. The labs results can be spread across tens of pages - I remember the neat hand drawn tables following these results pre-EHR. You would think it would be relatively easy to recreate that. I often make my own tables in Word and paste them in.

    None of it appears to have been made by an intelligent life form much less rise to the standard of English literature.

    Businesses taking over medicine and telling us how to practice have been a pox on the land. In this case they do not seem to have an adequate amount of pride in their work to produce a product that is superior to a single handwritten note. Back in the pre-EHR days nobody would have signed off on this mess.