Product Review: NextGen

November 25th, 2009

Just recently I evaluated 3 EHR systems (AllScript, NextGen and eClinical) and will gradually dump my notes into individual reports for each one.

 
NextGen (by Quality Systems (NASDAQ:  QSII)) provides an all-in-one solution, including PM, EMR and Billing.
 
 
 
Among the three, NextGen has the best user interface. It is intuitive and easy to use. 
The visual aid helps physicians to point and click their way through an entire exam.
 
 
   
   
 
NextGen EMR is completely integrated system and supports different specialties. It has a large selection of pre-built templates to help automate the workflow.  
 
Having said that, the product philosophy is that you will like the pre-built templates as they are. Adjustments are possible but that is relatively hard and would require engineering support. 
 
For example on HPI screen symptoms are listed as check-boxes in comparison to decision-tree-style selection lists that are used by many other vendors.
 
This is presented by NextGen sales as a competitive differentiator that removes the restrictions of sequential questioning needed in decision-tree pick lists.
 
 
NextGen EMR integrates with NextMD, which is the company’s patient-provider portal that facilitates effective electronic interactions between the patient and the practice.
 
 
The NextGen product is written in Visual Basic and Visual C++ and uses MS SQL database and Active Domain.  This implies an open architecture for custom developed extensions, such as integration adaptors and complex reports. NextGen has its own integrated word processing for creating/customizing letters and communication materials. The company is currently working on optional interface with Microsoft office.
 

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Product Review: PracticeFusion

November 8th, 2009
I have been recently exposed to PracticeFusion, a three years old player in EMR market. They offer a fully hosted (SaaS) PM and EMR system at no charge! (more about it below) 
 
The product is very easy to setup and use.  The user interface is self-explanatory and intuitive. Each top category of functionality has a short video tutorial that helps getting started.
 
Adding Patients, scheduling visits and dealing with charts is very simple. 
The only thing I didn’t like must was document handling, which is not as easy to work with, specially if you are dealing with lots of scanned materials. 
 
 
They have partnered with Digital Island to offer conversion of paper charts into electronic charts. 
 
As for billing, they offer own integrated billing system that charges about 6% of receipts that are received and deposited. Alternatively they offer secure email system for working with existing internal and external billers. I am not sure how well this will work!
 
 
The Web interface takes advantage of Flex 3, Adobe’s rich Internet application interface and the system backend is cloud-based and ensure scalability.
 
However as many other SaaS solutions there are few points to keep in mind:
 
Switching to another solution provider is going to be a nightmare. There is no easy way to get the data (which you own!) and move it to other hosted solution. 
So basically you are stuck with one SaaS provider as soon as you start.
 
Furthermore there is a question on what happens when Internet goes down; how would you access schedules and patients’ records during that time?
 
And finally, there is always challenge of integration in SaaS environment, in this case,
for example, integration with medical devices and instruments.
 
 
In terms of functionality E-Prescription is the most important missing piece, which seems to be a priority items on their roadmap. 
 
 
As for business model PracticeFusion plans to make money on free software by connecting advertisers with doctors while they are working on the system. Apparently they have already signed up advertisers such as Johnson & Johnson, AstraZeneca LP and Ortho-McNeil-Janssen Pharmaceuticals, Inc.
 
Given how difficult it is for a drug salesperson to get a doctor’s attention, the CEO, Ryan Howard, is convinced this business model will work.
 
For Physicians who don’t like to see ADs on their screen, an AD-free version of the solution is available at $100/month/provider.
 
For more info here is an interview with Ryan: 
 
 
In August 2009 Practice Fusion received an investment from SaleForce.com 
The investment is reportedly between $5 to $10 million. 
As a side note, to me this was an excellent strategic move by SalesForce, which is heavily focused in promoting its cloud platform.

 

 

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EHR to Bridge the Two Parallel Worlds

November 6th, 2009

These days I am spending some time on Process Improvements at Life Sciences and Pharma Companies. While doing so I noticed how much the Healthcare reform is going to help Life Sciences industry, indirectly.

 
Historically Life Sciences and Healthcare industry have been two strange and detached worlds.
But EHR related activities and standardizations, such as HL7, are creating more and more touch points for bringing these two parallel worlds together. 
 
The interoperability between EMR and CTM systems, and resulting interactions between Site Investigator and Primary Physician during Clinical Study are some of the obvious benefits.
 
On the technical side, I see CDA and CDISC to gradually converge on data structure, while utilizing XSLT for transformation at the end points to integrate clinical research data and health care data.
 
 

 

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The EMR war is still going on ..

November 2nd, 2009

 The EMR war is going on and will intensify in the coming years. Vendors are becoming more and more aggressive and innovative to gain and keep their market share in the rapidly growing EHR market. This competition will ultimately benefit EMR users with better products in the long run. But in the short term it will eventually make the buying decisions harder.

 
Among recent products updates is one from Praxis.
Praxis just announced a new EMR system that learns from the physician using it.
According to the company EMR templates reduce Physicians freedom of expression, as they are nothing more than a boilerplate developed by a third party or expert for inputting clinical data. The inflexibility of templates causes a series of problems during everyday use.
 
Praxis upcoming version 5 is using Neural Networks to overcome this inflexibility by letting the software adopt to Physician instead of expecting the other way around. 
 
Being fanatic about Artificial Neural Networks (ANN) I would like to see them succeed! 
If you are interested in learning more about Artificial Neural Networks read on my other site.
 
 

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NextGen revenue increased by 22%

October 30th, 2009

Quality Systems, the company behind NextGen product, just announced a 13% jump in profit and 22% increase in revenue.

 
The announcement said sales have recovered as health care providers have become more comfortable with the details of the American Recovery and Reinvestment Act of 2009, the federal government’s stimulus plan passed by Congress earlier this year.
 
As Steven Plochocki (CEO) put it:  "there seems to be a heightened comfort level in purchasing decisions relating to electronic health records systems.
 

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Clinical Document Architecture (CDA) explained

October 28th, 2009

Clinical Document Architecture (CDA) is an XML-based standard used for clinical document exchange within Health Level Seven framework. 

 
CDA has three levels of document definition, distinguished by the degree of granularity of the markup. Level One providing the least structure and Levels Two and Three providing increasing granularity.
 
Level One consists of Header, Body and HL7 Datatypes
 
Level Two includes Domain specializations 
 
Level Three includes full document semantics aimed to meet the machine processing requirement
 
 
HL7 Datatypes are defined for:
 
- Character strings and display data
- Codes and identifiers 
- Quantities
 
And Coded CDA components or elements are based on (SNOMED) and have the two-letter ending "cd". 
 

Here is an sample CDA level three:

 

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What does HL7 enablement means?

October 23rd, 2009
HL7 is about moving data, in form of messages, between software systems within clinical environment. In other words it is a messaging standard that enables clinical/medical applications to exchange data. 
 
Information sent using the HL7 is packaged as a collection of one or more messages, each of which transmits one record or item of health-related information. Examples include patient information, patient visit data. laboratory record and billing information.
 
HL7 standard specifies both exchange mechanism as well as message format and data structure.
 
The HL7 transport mechanism relies on an Event-Driven protocol, typically based on MLP or MLLP (Minimal Lower Layer Protocol) over a TCP/IP socket connection. (See Apache Camel project for an open source implementation of MLLP protocol)
 
MLLP act as a wrapper around HL7 messages to introduce a notion of atomicity over TCP/IP (which is a "stream-oriented" connection).
 
The HL7 requires every application that accepts a message to send an Acknowledgment message back to the sending application. The sending application is expected to keep on sending a message until it has received an Acknowledgment message (referred to as ACK).
An acknowledgment message consists of two parts:
1) An MSH segment, which contains information about the sending and receiving applications and a MessageID
2) An MSA segment, which indicates whether the message was accepted or rejected
The acknowledgment message should not be sent until the data in the HL7 message has been read and consumed.
 
 
The protocol relies on "open system architecture", meaning that anybody can interface with the system using appropriate protocols, independent of the vendor
 
 
Each HL7 message is made up one or more segments, which are the building blocks of HL7 messages. And each segment consists of one or more Fields.
Segments group related information together, for example the PID segment contains information patient information such as ID numbers, name, address and date of birth.
 
In the following HL7 example message, you can see that each HL7 segment is located on it’s own line.
 
Example: (MSH, PID, OBR, OBX)
 
MSH|^~\&|GHH LAB|ELAB-3|GHH OE|BLDG4|200202150930||ORU^R01|CNTRL-3456|P|2.4
PID|||555-44-4444||EVERYWOMAN^EVE^E^^^^L|JONES|19620320|F|||153 FERNWOOD DR.^^STATESVILLE^OH^35292||(206)3345232|(206)752-121||||AC555444444||67-A4335^OH^20030520
OBR|1|845439^GHH OE|1045813^GHH LAB|15545^GLUCOSE|||200202150730|||||||||555-55-5555^PRIMARY^PATRICIA P^^^^MD^^|||||||||F||||||444-44-4444^HIPPOCRATES^HOWARD H^^^^MD
OBX|1|SN|1554-5^GLUCOSE^POST 12H CFST:MCNC:PT:SER/PLAS:QN||^182|mg/dl|70_105|H|||F
 
 
The latest release of HL7 (V3) mandates both Human and machine-readable data structure. As such the documents are structured in a format referred to CDA, or "Clinical Document Architecture", based on XML.  (See my other articles on CDA topic)
 
CDA documents are not birth-to-death aggregate records, but a means for packaging information for transmission. They can include text, images, sounds and other multimedia content.
 
CDA documents are typically a MIME encoded payload within an HL7 message.
 

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$210 per compromised medical record

October 20th, 2009

 I was surprised to see the average cost of a data breach exceeded $210 per compromised record, creating an opportunity for computer crime rings to traffic in stolen medical records, according to a study sponsored by LogLogic.

 
The study shows patients may be surrendering their privacy as the $2.5 trillion medical industry pushes to accelerate the pace of digitizing health information records, prompted by federal stimulus funding.
 
 
According to the report the new HIPAA rules will help improving 
the protection of medial records. (see my post on new HIPAA rules)
 

 

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Cerner partners with CDW on EMR

October 19th, 2009

Cerner  just announced a partnership with CDW Healthcare to beginning Nov. 1 offer "one-stop" purchase of it’s ambulatory e-health record systems, along with hardware, technical assistance, and deployment services to small and mid-sized doctor offices.  This is the first time Kansas City, Mo.-based Cerner has agreed to offer its complete suite of ambulatory solutions through a national channel partner, according to InformationWeek.

 
This seems to be a strategy move in view of the rising demand and I expect other EMR vendors to pursue similar distribution models to accelerate market penetration.
 

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HIPAA and 21CFR11 overlaps

October 12th, 2009

Both HIPAA and 21 CFR Part 11 are concern with safeguarding Data. While 21CFR11 applies to Life Sciences Organizations (LSO), HIPAA applies to Healthcare Providers (HCP) and other "covered entities", such as insurance companies.

 
21 CFR Part 11 sets out the procedural and system requirements for controlling and auditing electronic records and signatures. It requires employing procedures and controls designed to ensure the authenticity, integrity, and, when appropriate, the confidentiality of electronic records.
 
Similarly HIPAA security rules are described as followed:
 
Physical Safeguards
Facility access controls
Work station use
Work station security
Device & Media controls
 
Technical Safeguards
Access control
Audit control
Integrity controls
Person or entity authentication
Transmission security
 
Administrative Safeguards
Security and access management
Secure incident handling
and implement policies and procedures to prevent, detect, contain and
correct security violations.
 
 
There are obvious requirement overlaps around
 
- Operational policies and SOPs 
- System and Record Access Control
- Audit trail
- Record keeping and retention
 
It just makes sense to start consolidating these requirements into one set. 
This has to happen sooner or later as we start sharing standardized medical records between healthcare providers and Pharmaceutical companies for Clinical Trials or Adverse Events reporting.
 
 

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