Home Forums Discussions General Discussion John Squire: "We need to deliver on our promises"

John Squire spoke to the meeting in Laramie, Wyoming organized by Indy and BestForYourPractice. In the course of a wide-ranging discussion with the group via Skype, he made the statement above and spoke on a number of relevant issues, with extensive Q and A. Here are a few other items of interest:

1. "A priority is releases delivered on time; high quality releases that perform as expected".
2. V6.6 is the highest quality of recent releases
3. AC is looking at "building-in" the New Crop functionality to improve the e-rx experience.
4. He has not finalized his thoughts about AC in the cloud, but "all the major EMR's are moving that way".
5. MU2 is a major focus with a release coming early next year. ICD-10 will include a "major educational effort" with a release later in 2014.

I don't mean to give undue priority to the statements above; he covered a wide range of issues, and these are just some of the ideas that stuck with me.
He seemed very "tuned-in" to the concerns of users, especially after such a short time at the helm of the company. The consensus of the group seemed to be that some concerns about AC's future were allayed, and to quote one attendee, "this might be the right guy to take AC where it needs to go".

At the ACUG meeting in Chicago, they stated they had to include SNOMED to meet certification (MU2?). One thing they pointed out was that they would crosswalk SNOMED to ICD 10 and it (SNOWMED) would make coding easier than ICD10. You could still do it in ICD10 if you wished. The time frame for this was by early summer so as to give time for implementation and traing before the Oct 2014 deadline.

Same theme as in Boston. I have hope. But $399/mo for PM doesn't keep my hope alive for that solution.

BTW - I need to find the original thread, but we missed Wendell, Leslie, and Martin in particular this time.

One of my take-aways is that Jon Squire is planning on transitioning AC into a software company, and that should be good for most of us.

There appears to be an increased willingness to partner with other companies to deliver value to users, and that should be good news as well.

This is what scares me. Usually with such transitions, companies start dramatically increasing licensing prices, often charging per user or forcing all users into the cloud. The fact that AC is available off the cloud is one the major reasons I am sticking with it. They also don't charge per computer/per connection like Microsoft with the CALs or numerous other companies.

Sandeep, from what you see of AC and its construction, what happens if we are totally happy with what we have, and never do another upgrade? Ignore MU requirements, ICD-10, etc..... assume we can patch around them. Is there some connection to AC that HAS to be maintained, or could we just continue to enter chart notes and if need be manually code and prescribe if our relationship with AC totally dissolved?

My concern, exactly.
I don't yet trust the cloud -- our internet is not that reliable.
Despite all the protestations of security, I don't believe that some of that data won't leak out.

If the internet goes down, there goes your data.

On the other hand, there is e-prescribing. At least for now that is part of the annual fee we pay to AC. I suppose we could get that standalone, but would it integrate with AC?

A few points.

First, I took Squire's implication that AC should focus on functioning as a software company as a positive. That started as their core business, and I think that it can only help them to stay focused on strong, on-time releases that do what they are supposed to do. The issue of cloud vs. home based software is a separate one.

He has a background in cloud software and he said that all of the "big" EMR's are looking to be in the cloud. On the other hand, he said nothing that suggests to me that he has decided to make that a focus for AC. Maybe he will take the company that way, but in my opinion it is likely that we will at least have the option of keeping the program in our offices (at least for the foreseeable future).

Having said that, I think it is appropriate for all EMR customers (not just those with AC) to have an exit strategy. What happens if you and the company part ways, for any one of a number of reasons (ranging from your own choice to the company going in a different, less desirable direction or even going bankrupt)? This was a topic at Laramie, not because of any specific concern about AC, but because JamesNT was smart enough to introduce the notion that we all need to plan for the possibility that someday we will choose to, or be required to, leave our current EMR. I likened it to the decision to have a will or to make your burial plans; you may not like to think about it, but it is risky to ignore the prospect. The need for such a plan brings up a number of associated issues such as getting access to your data, the ease and potential cost of acquiring it, and then your ability to enter it into your next EMR. I won't go into a full discussion of those issues here, but David's question above matched the conclusion of some at the conference. Namely, that "going off the grid" and maintaining a most recent, usable version of AC would be a viable option (and perhaps the best viable option, at least on the short term) if you don't care about MU and EMR penalties. The main thing you lose is eRx capability, and that can be maintained via stand-alone eRx software like Allscripts, albeit, as Tom points out, with a loss of integration with AC.

Can someone explain what this means? Does this mean they want to get revenue by another means? What are they if not a software company? Why are they talking about this kind of semantics when they have bigger fish to fry? Is this just "new leader has a vision" fluff or is it going to change our experience?

Jon, you explained my concerns exactly. We are not involved in MU, and have perhaps a 3-4 year practice horizon. An exit strategy is vital, and using version 6.5 forever would suit us just fine.

After Pri-Med bought AC last year, we started getting calls from concerned Doctors with the same perspective.

Our standard service delivery is to onboard an existing AC client quickly on a platform that can run without interrupts or tinkering for years to come.

For those that continue to operate in their office, that is why we recommend a RHEL/CentOS server that can host the AC 'server' far into the future long after Win14 debuts without having to upgrade Windows or AC. If the server also has terminal services onboard (or as a separate VM), the rest of the office can have moved onto Chromebooks, Macs, Linux, wearable computers, flex-screens - whatever. AC lives on it's own private enclave.

We talked extensively about this during the Meetup Weekend, so hit me up if you want more details.

Trying not to be negative, but I don't have much use for visionary leadership. I would be very happy with the new management if they:
-- fix the bugs
-- deliver on long requested features
-- look around at their competition and match the same set of services with the "kind capitalism" ethos that has distinguished AC for years
Ball's in your court, Mr. Squires.

If they want to survive, they will need to function as software company. That means timely releases that are well documented, functionality that works, and a steady diet of bug-fixes.

What it means beyond that depends on the paths that they choose. I have my own opinions about what they should do, but I'll post that on our own blog.

I'll say this much - I have worked for software companies, with them, and run a few, and they have no choice but to begin functioning as a software company.

What business choices they make are a completely different subject.

AC does phone home every so often to verify the practice. Some of us have seen how slow it can get with the Internet down and no prescription writing abilities. However, they cannot take the software away from you. Everyone here has purchased the license for the software. The support is separate and renews annually. Even in the cloud, you own that version of the product. Most other EMR companies will not give you rights to the EMR software so you can never own it. But like all activation, it can be circumvented by people with the right skills. Just ask Adobe and Microsoft who spend hefty sums of money implementing sophisticated activation measures. If it comes to that, people will be ready.

Well, I am preparing to be trained on Epic and am dreading it. So all of these concerns may pale and become insignificant once I remember just how intuitive and user-friendly AC really is. I am also very close to unhooking my AC database from internet access so I will let you know how that goes.

As I said years ago, be careful what you wish for.

"We are Borg Epic. Prepare to be assimilated. Resistance is futile."

My take on the Skype from John Squire (JS) in Laramie is this.

Dr Bertman created a great user friendly intuitive EHR (like Leslie says above) but it has it flaws,and some have been around awhile.
JS wants to clean up and make AC even better with his Microsoft/software background to make the product even better but not another EPIC.
Work on getting the portal going by integrating Updox.
Work on the PM with Medfx and the cost later to be determined.
Get the Newcrop e-Rx system working better.
By making a better AC product, it will continue to grow and expand in the small office setting.

My sense is that JS is very rational, pragmatic, and quite charming.
I liked what he said, how he said it, and how he answered some really tough questions without knowing or seeing his audience. (the video feed was not working)

I am quite pleased that he is running the show.

I do not think AC has been in this position before, with a change at the helm, but I think change is good.

Maybe I am an unrealistic optimist, but he has earned my respect, especially when he took time out of his busy schedule/family situation to Skype in to our conference the other day.

OMG! One day of training on Epic and it makes me wonder if I have been a "real" doctor's office these last 25 years! Someone please tell me what happened to common sense amd the "art" of the practice of medicine!

EPIC is proof that we don't really need doctors any more.
The administration and the IT folks, together with a proprietary version of Wikipedia can do so much more, and is much more efficient-- i.e., allows far more money to be transferred from patient and government accounts to hospital, insurance company and IT company accounts in far less time.

Leslie -- have you ever looked at the output of EPIC -- that is, what they send us from those big, fancy places that use it? That "synthetic prose", built up from a series of mouse-over boxes is just an abomination! Do you have any sense at all that somewhere a real patient is getting taken care of?

I presume this is all transitional -- but to what, I have no idea.
I suspect we go back to horse and buggy some time in not too distant future -- with medial records on 5 x 7 cards.

Highly reccomended -- Joseph Tainter's work on the "Collapse of Complex Civilizations."

Leslie, keep in mind what you do as a physician and what goes in the medical record are two only vaguely related entities, even with the old paper chart. The electronic record, AC included, makes them even more unrelated, which is why my rant about the use of templates. Just keep doing good medicine, and count on your knowledge of the patient to fill in the gaps on each subsequent visit. My guess is you will develop your own unwritten code for deciphering your notes when you next see the patient; i.e., that you only use the dropdown for "no fever or chills" to mean "worried well", but use "Low grade fever, mild chills" for "really bad URI." These things are just tools, some worse than others. They are not the goal. Try not to despair.

Most EMR's -and EPIC is a prime example - are not designed for the purpose of medical record keeping. They are designed to maximize billing and to maximize the ability to standardize and allow the extraction of data for reporting.
These functions of an EMR are not congruent with (and sometimes are in direct opposition to) our goal which is to keep a record that is readable to us and other docs.

When I first started using an EMR back in 1997 (yes the dinosaur age) I did it because I was too cheap to pay a transcriptionist. The software at the time (SoapWare) gave me the ability to type my note in a consistent fashion and produce legible notes for me and consultants. Then, I thought, hmmmmm, this is a useful feature being able to produce a data base which showed me what patients were taking Voltaren or the like. Then, I thought, hmmmm, this is nice being able to call up all patients over the age of 65 who have not had their Pneumovax. My point being, every module I added I did so because it helped me take better care of my patients and made record keeping FOR ME easier.

Unfortunately, The concept of the EMR has now degenerated into not what makes things better for the physician or for the patient but for the intruders....government, insurance, big pharma. The belief that the collection of all of this granular data will improve health care has not been proven to suit me. I have been downgraded from a physician who liked to spend time with my patients to a data entry clerk. I now am measured not by whether I actually made the patient feel better but by how efficiently I clicked here, clicked there, said I did things I may or may not have done just so I can close a fricking note. No wonder there is a physician shortage....it is not because there are not enough physicians to go around but because those physicians are forced to spend so much time away from seeing patients!

Believe me, I do not blame my new employer....I sincerely believe they do not like it any better than I but facts are facts....if you expect to get paid, expect to produce the end-product the payors demand. The tail is now wagging the dog and along with it, the poop it is covered in! I would throw up my hands but my carpal tunnel hurts too much.

Couldn't agree more, but then we always agree. What has always bothered me the most is that I bought Amazing Charts, because I wanted to practice better medicine. But, then the government payed doctors to purchase an EMR.

This is the tip of the iceberg.

For being relatively bright folks, as a collective group, docs are on par with dimmest of the dim.

Can you imagine lawyers being driven by droves by chicanery into utilizing EHR's like Epic? To then be asked to perform all the data entry to further regulate their pay downwards, with the end result of diminished and less efficient care and do nothing to reduce liability.

And to add insult to injury, have no way of extricating themselves from the mess, now dependent on governmental incentives to keep the whole thing afloat.

With the hope of decreasing collective cost of health care to society.

This is all madness.

However, on a microcosmic level, I have never felt better about my own practice and being able to keep not only the science but the art of medicine alive to share with my patients with the current tools at hand.

@ Leslie,

I have a thought about incorporating carpal tunnel into your signature

Jimmie, I disagree we "have no hope of extricating ourselves". To start with, I decided to forego the incentive money because frankly it is just not all that much. If I can see one extra patient a day over the course of the last 4 years simply because I am not burdened by all the worries about documenting everything "just so", I more than make up the difference. This leaves aside the fact that I find my job largely pleasurable and minimally driven by documentation worries, because I use AC as a tool to help me, not dictate how I work. I think that too many practices are chasing a carrot that is actually a very small incentive, and very bitter when eaten.

David,

My point exactly, and I was not quite getting my fingers to do what my brain wanted.
I am trying to differentiate those docs that utilize EHR's like Epic/Nextgen and those that use AC/Updox.

At least the AC user has the ability to extricate himself from MU/PQRS if it is in his best financial interest to do so.

I find it quite liberating and refreshing to practice as you do.

So there is hope outside the "machine".

AC certainly is working to achieve MU 2 certification. On the other hand, I think they are just becoming aware that participation is not in the plan for all of us (even some who have received MU1 incentives).

Are most people planning to participate in MU 2, or not?

I have 7 partners who want to buy AC, but it now hinges on AC getting MU2 certified.....

MU2 will be the least of the new user issues if they can't bill.

I love AC but do not sell 6.6.1 until the billing bugs are worked out.

Couldn't agree more with your experience, Leslie. David may not be interested in the MU money. However, the incentives and payment reductions are only the beginning. All of these mandates will soon be pooled together and will eventually have many more repercussions. For instance board certification status, insurance paneling and possibly even licensure will be tied in. This is all very real and most medical associations appear to be very supportive of the mandates.

It seems with all the requirements MU2 / PFP etc. We like Dr. Fairbanks have not grasped it nor have we been forced to yet.
Because we are not my paper chasing seems less invasive. It seems that I am gravitating more and more to direct care and dumping insurances all together.

I dont want to be perceived as a rich guy doc but it sure seems attractive to go back to spending time with patients and not worry about insurance.

Sorry on a major rant today.

I'm with Frank. I think we have to change, so embrace change, change in small amounts instead of delaying the inevitable, and minimize stress. We adapted to medical records needing to satisfy insurance companies. Now we have to start learning how to satisfy the government.

Of course, this whole thing would be better if we had a constitutional amendment that lawyers had to have the same record keeping regulations as doctors. Justice ought to be a right more than healthcare. Politicians and regulators wouldn't mess with them.

If and when licensure is tied to Medicare/Medicaid participation, then our choices will be reduced.
Meanwhile, I prefer to see these (MU, PQRS, etc) as incentives rather than requirements. So we get to make the call: is the time and energy to participate in these programs worth the financial return or not? Do we think they will improve the quality of care we deliver or not? It is still OUR decision.
As Jim says above, "the AC user has the ability to extricate himself from MU/PQRS if it is in his best financial interest to do so".