Before you can hit a target--or a market--you have to take aim.
In the marketing war over electronic medical record systems, dozens of software developers are deploying multiple strategies to hit their targets: medical practices.
Some developers are aiming at clinical niches, like oncology or emergency rooms. Other vendors are offering systems they say accommodate any practice.
Some are targeting only large practices. Others are gaining ground by winning over single and two-doctor practices.
Some vendors are going it alone; others are forming alliances with drug companies. Many are going wireless, but a few are not. Some are leasing their systems using an application service provider (ASP). Some are sticking with the traditional license model, in which customers buy and own their software outright.
Physician executives can save time in evaluating EMRs by understanding the marketing strategies of the vendors and comparing them with the size, goals and styles of their practices.
It's going to take a while to find out which strategy will win the war, says market analyst Vinson Hudson of Menlo Park, Calif. By Hudson's count, 138 EMR vendors are battling for market traction. In 1997, EMR adoption rates were low, with vendor revenues estimated at $670 million out of a potential $7.6 billion market, based on his market surveys. Hudson projects sales to grow to $800 million of a potential $8.4 billion market by 2002.
When electronic physician practice management systems hit the market, it took about 10 years for them to become widespread, and even today, a few physicians still keep their books on paper, he says.
Using the PPM system adoption rate as a guide, "if your (electronic) medical records came in in 1995, you've got until 2005 until we have some good level of acceptance," Hudson says.
One key difference among EMR marketing strategies is whether the vendor offers a full-featured system or one that comes in modules.
Full-featured systems contain all their bells and whistles in one version of software. Once the system is deployed, any or all functions can be used as soon as the physician learns to use them. The downside of these systems is that physicians pay for an entire system while they climb the learning curve. The upside is they do not have to wait to deploy a new module when they want to try the next function.
Vendors of modular systems sell physicians the software to perform only the functions they want to use. The goal of either strategy, Hudson says, is for physicians to realize a personal benefit from using the software. "Until you get to that, it's a problem."
According to the AMA, a third of all doctors are in group practices and a quarter remain as solo practitioners, creating two different markets for EMR systems vendors. Morgan Coleman, sales and marketing director for Seattle-based Physician Micro Systems, a company that has been selling EMRs since 1994, estimates no more than 2% of physicians are using EMR technology.
Patricia Wise, executive director of CPRI-HOST, an EMR advocacy group in Bethesda, Md., says 15% to 20% or more of medical practices have some form of medical record system, if you count scheduling systems and computerized prescription writers as component parts of an EMR.
"It depends on what you count," Wise says. "If you're talking about paperless offices, the number would be very small."
A4 Health Systems of Cary, N.C., sells hard-wired systems, but about half of its 135 EMR system installations are wireless and about 95% of its sales the past year were wireless, says David Bond, vice president of sales and marketing.
Bond says A4 sales representatives try to cinch the deal with a doctor by using a kit that includes a laptop, a notebook computer, an antenna and a connector, called a hub.
The representative plugs in the laptop to use it as a server, hooks up the hub and antenna, then puts the notebook in the doctor's hands.
"He starts walking around and says, 'That's cool,'" Bond says. "His confidence level rises. If the doctor starts using it, you've got one hook in the doctor's mouth."
Wireless systems can be quickly installed in small offices where A4 markets, he says. Prices of radio frequency components have dropped dramatically in the past 18 months. A two-physician wireless EMR setup, including hardware and software, runs in the low $40,000 range, or about $900 a month on a lease-purchase agreement, Bond says.
"The key in this market is happy references," he says. "That's what sells EMRs. If you get one group in a town who starts to use it, it's amazing how many people will call you."
iMedica of Mountain View, Calif., rolled out its wireless, all-in-one PhysicianSuite EMR in January 1999 after three years of development.
The iMedica approach was the one used by most EMR developers--find a group of doctors willing to be guinea pigs in a painstakingly slow series of experiments in which the new system is worked over function by function.
According to CEO Charlie Koo, iMedica first tried developing a one-function tool to use as a Trojan horse to get into physicians' offices.
"Nobody would take it," Koo says. "If anyone thinks they're going to launch a product that doesn't have it all, they won't make it."
Adjustable templates in the iMedica system make it adaptable to most specialties, Koo says.
Jeffrey Michaelis, M.D., an internist in a two-physician Brewster, N.Y., practice, says he and his colleague decided from the start to buy a full-featured EMR because they felt it gave them maximum control. Michaelis says they had confidence they could learn the system. And they wanted wireless because it offered a cost advantage. Their iMedica system should be installed this month, he says.
"We're very independent," Michaelis says. "We don't want anybody else telling us what to do."
"What we are going to do is implement it slowly in a different way. Initially, we'll use it as a prescription writer and use it for a few patients a day as an EMR and print those charts out. Eventually, we'll roll it up."
Michaelis says they picked a wireless system for its economy and its mobility.
"We didn't want a PC in every examining room," he says. "(Wireless) is cheaper, and we really didn't have room."
The overwhelming favorite computer among wireless EMR vendors is the Fujitsu touch screen. The Fujitsu Stylistic 3400 is the company's latest, says George Wintner, senior account executive. The 3 1/2-pound computer takes up slightly more area than a sheet of typing paper, is a little more than an inch thick and has a color screen that measures 10.4 inches diagonally. Battery life is an unimpressive 3 hours, but a doctor can swap out its rechargeable battery pack in seconds with no loss of data.
Wireless, particularly with the higher cost of the computers, is not the universal solution, says Gerard Daher, business development manager for EMR developer Noteworthy Medical Systems of Cleveland.
Crain's Cleveland Business reported in November that more than 90 doctors, nurses and secretaries at the Cleveland Clinic use the Noteworthy EMR system. A spokesperson for Cleveland Clinic declined to comment but said he took no issue with the accuracy of the report.
None of the systems Noteworthy sells are wireless, Daher says. He argues that for $700, a hospital or clinic can buy a powerful personal computer, and for another $1,000, a 17-inch, high-resolution flat panel monitor "that no one's going to walk off with or drop."
The price difference between a desktop computer and a top-end $4,200 Fujitsu may be minimal in a one- or two-doctor office, but it is "staggering" when multiplied out over hundreds of doctors at a clinic or hospital, Daher says.
Douglas Blayney, M.D., of Wilshire Oncology in Pasadena, Calif., admits making a mistake when his five-physician, five-office group bought an EMR system. The group purchased a system from iKnowMed of Berkeley, Calif., a company that does not offer a wireless system.
They like the iKnowMed system, he says, but against the advice of company installers, the group placed desktop computers in some exam rooms but not in others. This varied setup requires Blayney and his colleagues to sometimes complete a chart outside the exam room on a centralized computer at the nurse's workstation.
"We didn't want to have a computer intrude between the physician and the patient, and we didn't want to go to the expense of putting a computer in every room," Blayney says. And that was the mistake, he says.
"I find that it's a much easier work style to talk with a patient (and use the computer), as opposed to having the computer at the central working station."
Blayney says having the computer in the room is no intrusion on the patient-physician relationship, as he first thought it might be. Rather, the computer helps the physician connect with the patient, he says. Blayney says he routinely gives his patients printouts of notes from their visits.
"Cancer is an emotion-laden illness. This morning I had three new cancer patients. I had a note for them to read and review and ask questions--everything I would send to their referring doc--as they walked out the door. And it was legible.
"Taking notes in the presence of the patient sends them a message that I'm listening carefully to what they say and I am recording accurately what they say and I'm keeping nothing from them. The patients like that."
iKnowMed is focusing on oncology and is offering its system only as an ASP. It has been sold only on hard-wired systems because there has been little demand from oncologists for wireless, says CEO Richard Barker. The system accesses a data base that automatically determines whether a patient is eligible for any of a continuously updated list of clinical trials. iKnowMed's ASP system and its focus on oncology helped close the sale, Blayney says.
"We have five doctors and five offices, so we thought the Internet-based system was a good solution," Blayney says. They chose iKnowMed because it was focused on their specialty, he says.
Like Michaelis, Blayney and his colleagues bought an all-inclusive package.
Blayney says he and another colleague took to the system quickly, while two others are having a harder time and one "who has not had much (computer) experience is slow to adapt and has really dug in his heels."
Blayney says using a template-based system forces him to conduct a more structured patient exam.
"Physicians don't think that way so often, so that takes some getting used to," he says. "The first two weeks were brutal, and now I get all my note documenting done during clinic time. Usually I would do that out of clinic time. It's now about three months into it, and I think I am as facile now as I was with our paper-based system."
Bob Elson, M.D., medical liaison for iMcKesson Provider Solutions Group, a division of San Francisco-based McKessonHBOC, says the modular system is the way to go and prescribing is the place to start.
"There is nothing little about prescribing," Elson says. "Once you've gone through the conversion to online prescribing, once you've gotten doctors and nursing using the infrastructure and you have the devices deployed, stepping up to a full medical record is almost a baby step.
"If there is anybody up there jumping up and down about doing it all at once, it's a defensive approach," Elson says.
Physicians at the Kokomo Family Care Center in Kokomo, Ind., were drawn to iMcKesson's four-module PracticePoint system because "they could do it bit by bit," according to Cheryl Norris, executive assistant at the 14-physician group that rolled out iMcKesson's prescription writing module in September 1999.
All 14 doctors were writing e-scripts after three months, Norris says. The lab module came next, and so did a glitch. Doctors started receiving lab results late last summer, but are still unable to send orders to their main lab, which delayed connection because the lab was planning to move. The ordering piece should go online Feb. 23, Norris says. The group started rolling out its charting module last fall and eight of the doctors are using it now, she says. Norris says incremental implementation is the way to go.
"We are a large practice. We have approximately 120 people in support staff. You need to bring those people onto the system, too. To do it all at once would spell doom for the system. Everybody has a different learning curve."
Allscripts of Naperville, Ill., completed its merger with Channelhealth of Burlington, Vt., in January, adopting Allscripts Health Solutions as the new name for the combined company. The company also renamed all eight of the modules of its EMR suite, now called Touch Works Enterprise.
Allscripts, which has partnerships with drug marketers IMS Health and Express Scripts as well as software systems developer IDX, is targeting practices of 75 physicians or more.
Jeff Soble, M.D., is a member of the 35-physician University Cardiologists group at Rush Presbyterian-St. Luke's Medical Center in Chicago. The group has installed two Touch Works modules so far, for transcription and lab work, and is ramping up its prescription tool in a segmented roll out that Soble sees is as much a re-engineering program as an EMR system implementation.
With a module system, physicians and administrators can take those workflow problems that need attention and focus on them, he says.
"I can tell you the Channelhealth approach is much smarter," Soble says.
"You don't have to swallow it all at one time. You can take it in doses, prioritize and pay for what you need."