Government EHR Program: Potentially Harmful Unintended Consequences
I am really intrigued by the latest creation from the Department of Health and Human Services (HHS). Last week, HHS announced a contract to set up a group of experts to identify and attempt to fix any “undesirable” and “potentially harmful unintended consequences” that result from the stimulus legislation’s EHR incentives. According to the announcement, which was posted on the Federal Business Opportunities website: “Historical experience, as well as mounting evidence of unexpected problems, demands that we consider potential downsides.”
My curiosity is piqued! What are the unexpected consequences the government anticipates, and why is HHS so concerned? Awaiting the report from the panel of experts, I started thinking—and it didn’t take me long to create a list of my own.
My top three unintended consequences are the following: (If you’d like to suggest other potential unanticipated consequences—positive or negative—please submit a comment at the bottom of this page.)
- There will be more EHR failures than successes, particularly among high-performance specialists.
- “Certification” will stifle innovation.
- Productivity and physician-focused EHRs will lead the market among high-performance physicians.
More EHR Failures:
After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. (5) Physicians will try to transfer data entry tasks to scribes and other lower-cost employees (assuming that the regulations allow CPOE to be done by other than the ordering provider), but this strategy will not make economic sense, either, since the additional costs will outweigh the government incentives. The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.
“Certification” will stifle innovation:
Innovation will suffer, as it did in the past when many EHR vendors devoted all their development resources to complying with the long list of CCHIT-certification requirements. Forcing all vendors seeking certification to meet the same criteria will surely sap the drive for innovation. As vendors burn through precious development resources to meet evolving government standards instead of improving their core product, they will fail to respond to the interests of their customers, i.e., the physicians. Sales and marketing will drive physicians’ choices, rather than the EHR products themselves. Large companies, which have the largest sales organizations and marketing budgets, will be successful in the short term. Smaller vendors who follow the herd instead of their entrepreneurial and innovative instincts will be driven out of the market.
Productivity and physician-focused EHRs will lead the market:
The good news is that innovation will triumph in the end. Alternative solutions—like the hybrid EMR—will prevail as high-performance physicians find success with products that focus on their needs and enhance their productivity. It will take 4 to 5 years for physicians who have experienced government-program EHR failures to reapproach the market after amortizing their losses. These physicians will seek products that focus on clinical-workflow efficiency and physician productivity. The long-term winners in the EHR market will be those vendors who resist the temptation to chase the “windfall” stemming from the stimulus legislation, and instead focus on improving their products to deliver these benefits.
Please share your thoughts on other possible unintended consequences by submitting a comment below.
Meaningful Use Rule: Initial Comments Set the Tone
It’s been a relatively quiet week—the initial reactions to the proposed rules on “meaningful use” and standards are out, and the flood of commentary has temporarily subsided. The work of reviewing and analyzing the rules in depth has just begun, as staff at various industry organizations pore over the 700 pages of government verbiage at a more detailed level to evaluate how their respective stakeholders will be affected. We are actively participating in such conversations, and a number of leading organizations—MGMA among them—have reached out to us to talk about the implications for physicians. I hope that they will take our input into account as they formulate their recommendations.
Although it is anticipated that the vast majority of public comments will not be submitted until the final days of the 60-day comment period—i.e., in early and mid-March—individual physicians and others have begun formally registering their opinions. Not surprisingly, some of the initial comments reflect anger about the length and complexity of the rules themselves. Urging the government to keep the requirements simple was a common theme among comments from physicians and administrators:
“If the goal is to get the majority of clinics using EHRs and to provide incentive funds to help the economy, then the first step of incentive payments must be easy to obtain.” —Craig Brauer
“The ‘meaningful use’ criteria should provide incentives to encourage the implementation of the most essential features of an EHR, but it is imperative that the ‘meaningful use’ criteria not become a Christmas tree of features that becomes hugely expensive and unworkable. The ‘meaningful use’ criteria must not make perfect the enemy of the good.” —Robert Rauner, M.D.
Others talked about the limitations of traditional EHR products and issues of usability:
“I am concerned that the current emphasis, promoting adoption of existing EHRs, with little focus on the need to make EHRs better, will ultimately slow innovation. . . . Usability is the Achilles heel of current EHRs. An EHR may meet all of the functionality requirements and yet be so burdensome to use that patient care is made more difficult. . . . At this point we don’t need more EHRs, we need better EHRs.” —Christine Sinsky, M.D.
Objections to CPOE and the effect on physician productivity were also common:
“The process of entering orders is often inefficient and time consuming, with multiple screens, drop-down boxes, scrolls, and clicks. Assigning these clerical tasks to physicians results in a redirecting of limited physician resources away from clinical work, replacing direct patient care with low value added clerical work.” —Christine Sinsky, M.D.
To view these and other comments, or to submit your own recommendations, go to regulations.gov.
On a lighter note, a few days ago, I read a parody in HIStalk (a venerable healthcare IT blog) called “Marry in Haste, Repent at Leisure: Choose Your EMR Soul Mate Carefully.” It compared purchasing an EMR to getting married, and the analogy is a good one. Mr. HIStalk, the blog’s author, postulated that “the same handful of wrong reasons that convince people to marry unwisely also convince them to buy EMRs that will make them unhappy.” If you are interested in reading more, go to HIStalk.
Meaningful Use: Hype and Misinformation Still Abound
In the wake of the release of the CMS Proposed Rule regarding “meaningful use,” one would expect that the mist would begin to clear and facts emerge. But it seems that as the hype intensifies, so does the dissemination of misinformation.
A consensus among physicians is growing. They rightly feel that the government’s expectations are overly complex, burdensome, confusing, arduous, etc., and that the adoption of a traditional EMR is fraught with peril. The following are two of the comments I received on last week’s EMR Straight Talk:
“I have been ‘paperless’ for 6 years. For most of that time when I have complained about the cost and the increased physician time I have been ridiculed even at the AMA level. The expense is astronomical and there is no way to recoup the cost. I have been in private practice for 35 years and EMR is the biggest mistake of my career. It is somewhat comforting to know that others are evolving to my way of thinking on EMR. I feel this is the brainchild of the IT industry with little or no input from those actually using the systems. Thanks.” —Lee Schoeffler M.D.
“There is another huge ‘cost’, which is the creation and then electronic perpetuation, ad infinitum, of incorrect medical information. I have yet to find a patient encounter spit out by an EHR in which I could easily understand what was wrong with the patient. The automatically generated reports are often in a new language, ‘digmedgib’, for digital medical gibberish. I have read reports from ‘excellent’ EHR systems (one of which is utilized by one of your sources quoted [in another of last weeks comments] which contain disastrous errors created by a 0.5 mm slip of the mouse pointer and a click. This is what happens when two opposite diagnoses differ by one consonant and are adjacent in the pull-down list. We are trying to treat the patient but we are really doctoring the EHR.” —Sandra Brown, M.D.
David Brailer, M.D., former “Health IT Czar,” whom I quoted last week regarding the likelihood that penalties for non-participation will be dropped, also forecasted that “we’ll be approaching the peak of the hype cycle” before a “real slide back to reality,” with CMS money coming “slower than everybody thinks.” Like me, he recognizes the challenges the legislation presents for physicians.
In light of the 556 pages of publicly available, detailed information about the “meaningful use” legislation, I find shocking the amount and level of misinformation being perpetuated by even the most reputable—or so one would expect—sources of healthcare information. I was appalled by the following ad that the Cleveland Clinic ran in the New York Times recently:
The fact is: EHRs are not required—not now and not in 2014! The legislation explicitly states (in section 3006 (a) (1)) that participation is VOLUNTARY. Shame on the Cleveland Clinic for such a flagrantly irresponsible ad!
Less unexpected is the perpetuation of other myths by vendors of traditional EHRs—those with the most to gain financially from the legislation—concerning the alleged ease with which their products will facilitate the achievement of “meaningful use.” The well-respected EMR blog, HISTalk, recently invited CEOs of EMR companies to address 6 questions related to “meaningful use”, and is currently running a series containing their answers. You can read Part 1, Part 2, Part 3, Part 4, and Part 5 of the series so far, and it will probably come as little surprise to you that my responses are strikingly different than those of the other 9 CEOs! But my opinions do not appear to be in the minority when it comes to how physicians view the legislation, as you can see by the following comments HISTalk received:
“Could not agree more, except perhaps to extend the ‘extremely burdensome’ costs considered as not only financial, but also temporal and operational. In our little office, the greatest bane is workflow adjustment. There are just so many hours in a day and, functionally, our primary focus during most of them is to care for patients, not figure out how to enter data, collect stats, tweak templates, and distribute meaningfully to the cloud.”
“Frankly I am surprised that a couple of these guys (namely Girish and Pead) seem to believe that the 80% CPOE adoption will be so easy. Either they have incredible confidence in their software and the ability of their staff to affect change management, or, they are incredibly out of touch with the culture of your average physician practice. Steele is correct is suggesting it will be a huge challenge and Skelton understands that the transition will be more difficult for private practices and specialists in general.”
And just yesterday on HISTalk Practice, Dr. Gregg Alexander, a self-proclaimed “grunt-in-the-trenches pediatrician and geek” agreed:
“It feels as if the voices which ring most true to my trench-weary ears are not the ones being heard most loudly nor echoed most frequently. Most of the big brains of the industry, be they governmental guiders or corporate cognoscenti, seem to be enraptured with the power and the glory of the Meaningful Use Criteria [MUC]. . .The majority of healthcare in the U.S. is provided by smaller players who have no I.T. team, who have techno-illiterati-filled staffs, and who really want to focus on doing what’s right for our patients, not our data centers.”
Your voice counts. On Tuesday, the voters in Massachusetts made their feelings known, and we will see the impact shortly. Keep speaking out, and I will too.
Readers Respond: The Exorbitant Cost of Meaningful Use
As anticipated, the release of the proposed rules on “meaningful use” created quite a lot of conversation in the medical community. Physicians are realizing that the waiting is essentially over, and that the final version of the requirements will not lessen the onerous burden the government is placing on them in exchange for the possibility of a paltry $44,000. And don’t be intimidated by the government’s threats of penalties for not complying with its voluntary program. Not only are the penalties in the legislation quite small relative to the potential risk, but they also would not begin until 2015—if they are imposed at all. According to a recent interview reported in Healthcare IT News, David Brailer, M.D., former “Health IT Czar” and one of Dr. Blumenthal’s predecessors, “doesn’t believe that Congress will follow through with penalties and will either delay or phase them out.“
Last week’s EMR Straight Talk attracted a great deal of attention and elicited a number of interesting comments, some of which I would like to quote and respond to here.
Erin Goshorn, M.D., wrote:
“We have an excellent EMR in our subspeciality ophthalmology and ENT practice, which consists of 50+ providers. I thought that eventually EMR would increase efficiency and the extra time required to input data would go away. However, after 3 years of putting up with the inefficiency in my clinic created by EMR; I finally conceded. I now schedule 6 less patients a day and had to hire an additional skilled technician at 37,500 per year.”
Dr. Goshorn’s experience is typical of what I hear from physicians in a wide range of specialties. Although I don’t know the particulars of her practice’s finances, I did a little digging about the economics of the average ophthalmology practice. A decrease of 6 patients a day could easily represent a loss of $150,000 in annual revenue ($750,000 over 5 years), assuming that she sees approximately 40 patients a day and generates $1 million in revenue—and that’s before she devotes the additional time required to try to meet and report on the 25 meaningful-use measures.
Nick Orlowski pointed out:
“Great post, but you forgot a major additional cost. The costs you quote are accurate if the rollout and purchase work without a hitch. If you implement an EMR product, only to find out that it is the wrong product or doesn’t do what it has promised, you are out at least double your initial purchase cost, probably more!”
This comment alludes to the historically high failure rate of the type of EMR the government is encouraging physicians to adopt. Despite all the evidence—lack of landmark studies showing positive benefits to physicians, negative feedback on the government’s FACA blog, and discouraging comments submitted in the Voice of the Physician Petition, the government expects physicians to take the risk of proceeding down a path that leads—50%-80% of the time, according to the author of a recent landmark study—to a failed adoption attempt.
Another physician—a surgeon—challenged my financial analysis, charging that the meaningful-use requirements really only affect his time in office visits.
Since the bulk of his income comes from surgeries and other procedures, he maintained that I had overstated the impact. Unfortunately, this is a common misunderstanding of the economics of medical practices and ignores the impact of “leverage.” Office visits generate all other revenues—if you reduce the number of these visits by half, then your surgeries or other procedures, diagnostic tests, injections, etc. are also cut in half. Therefore, changes in exam-room productivity—such as the effect of trying to meet each meaningful-use measure—result in large changes in total revenue. Among the most highly leveraged specialists are orthopaedists, for whom every hour in the exam room generates approximately $1,000 in total revenue.
Steven Finch questioned:
“These #’s are terribly inflated and seem pulled out of thin air. I am curious how you attained them or what research you did to find them. I work with physicians who have implemented EMR systems in their practices everyday and they all agreed that not only are your #’s way off, your reporting is irresponsible at best. I would suggest going back to the drawing board and making another attempt.”
Actually, I would argue that if I erred, it was on the low side, since the numbers quoted do not include the cost of lost physician productivity. However, let me address Steven Finch’s allegations. Most of the numbers come from the government’s own published estimates or from industry (MGMA) data. To review, here are the numbers I used in last week’s blog:
| Capital cost to purchase point-and-click EHR: | $54,000 | 1 | |||
|---|---|---|---|---|---|
| Annual maintenance & training ($10,000/year): | $50,000 | 2 | |||
| Cost of reporting for 5 years (9 hrs/year of physician time): | $22,000 | 3 | |||
| Cost of additional staff needed to input required data: | $75,000 | 4 | |||
| Total: | $201,000 | ||||
1 The capital cost is stated in the CMS Proposed Rule on Meaningful Use, in the table on page 361, and includes all the acquisition and implementation costs.
2 $10K/year for annual maintenance comes from the same table, and includes ongoing training and upgrades that will be necessary as vendors change their products to keep up with the increasingly stringent requirements for “meaningful use.”
3 In the same table, the government estimates that it will take physicians 9 hours/year to report and document their “meaningful use” for the government. Using MGMA estimates of average physician revenue, this comes to approximately $500 per exam hour for primary-care physicians, and considerably higher for specialists.
4 The cost of additional staff time is an estimate—I believe a conservative one—based on the anticipated need for one staff member for every three physicians to input the information a physician would typically not input, at a cost of approximately $15K/year/physician. Even if you took this number out of the calculation entirely, the costs far outweigh the potential incentives.
Add in the cost of lost productivity (use Productivity Calculator to estimate), and it is clear that the government’s EHR program is a losing proposition for high-performance physicians.
The New “Meaningful Use” Rules: Is Participation Worth Your Time?
The government has finally released its long-awaited “Notice of Final Rulemaking,” which defines “meaningful use” under the Stimulus legislation and spells out the associated regulations. In 556 pages, the document lays out what physicians must do—in addition to implementing a qualified EHR—to meet the meaningful use requirements and earn the EHR incentives. The bottom line: Purchasing a “government EHR” is a money trap for high-performance physicians—particularly specialists.
The new meaningful use requirements are virtually the same as those recommended by the HIT Policy Committee back in July, which means that the requirements remain onerous and unreasonable in terms of the burdens placed on physicians hoping to earn the incentives. There are 25 meaningful-use objectives and related measures, and every one of them must be met every year for a practice to qualify for the incentive money.
Economics clearly do not support participation in the incentive program. A physician must incur the following costs in return for a potential $44,000 earned over five years:
| Capital cost to purchase point-and-click EHR: | $54,000 | * | |||
|---|---|---|---|---|---|
| Annual maintenance & training ($10,000/year): | $50,000 | * | |||
| Cost of reporting for 5 years (9 hrs/year of physician time): | $22,000 | ** | |||
| Cost of additional staff needed to input required data: | $75,000 | *** | |||
| Total: | $201,000 | ||||
| Notes: | |||||
| * ** *** |
Government’s estimate presented in the proposed rule. Estimate for average specialist; see Physician Productivity Calculator. Assumes one nurse shared by three physicians @ $45,000/year. Staffing is based on Phase I of meaningful use requirements and will increase with the more stringent requirements of Phases 2 and 3. |
||||
This $201,000 five-year loss doesn’t even factor in the exorbitant costs of the lost physician productivity associated with the implementation of a traditional EMR. Nor does it account for the risk of a failed adoption attempt or the inability to achieve meaningful use to the satisfaction of the government.
My concerns are not unique—it is clear that skepticism and doubt abounds among industry stakeholders:
- The length of the document alone should give physicians pause. As A. Cavale, M.D., says in one of the first government blog posts related to the proposed rule:
“If the ONC really wants practicing physicians to read and understand any such criteria, it has to be cognizant of the size of such documents. It would be nearly impossible for a clinician in private practice to dedicate that type of time to read a 556-page document, understand it and implement it.”
- William Jessee, M.D., CEO and president of the MGMA (Medical Group Management Association), wrote in a letter to CMS:
“Overly burdensome requirements and needlessly complex administration will only discourage physician participation in the program and the implementation of EHRs.”
- HIMSS, the EMR-vendor association, issued a warning:
There is still “much work to do within healthcare regarding simple adoption [of electronic health-record systems] well before we can achieve meaningful use of the IT. . . . This foundational work—while required—will likely result in provider uncertainty about which IT products to adopt, costs through adoption of ever-maturing IT over time, higher costs associated with a need to support multiple standards, and somewhat delayed improvements in patient outcomes and costs.”
- HISTalk (venerable healthcare IT blog, 1/4/10) summarized the level of concern:
“Doctors were already avoiding EMRs because of cost and negative workflow impact. Providers are questioning whether they can qualify for the incentives and whether they trust the government to pay them. . . . If you’re a provider trying to decide whether the government money has too many strings attached, this might convince you that it does. And if you asked me how the odds of high EMR utilization changed with the release of these proposed requirements, I’d say they got worse.”
What physicians should focus on instead of the government incentives is implementing a proven product like the hybrid EMR, which helps them operate a highly productive practice where patient care and efficiency are key.
Research Explains Why EHRs Won’t Achieve “Meaningful Use”
A new landmark study on EHRs was published this week, and its implications for widespread physician adoption of traditional (“legacy”) EHR technology—particularly by high-performance specialists—are dismal. Published on December 14 in the well-respected Milbank Quarterly, the study represents the most thorough EHR analysis to-date, basing its conclusions on an exhaustive review of 195 previous studies. Confirming the previously acknowledged EHR failure rate of 50%—quoted by then “IT Czar” David Brailer, M.D.—the lead author estimated the actual failure rate to be as high as 50%-80% of implementations, as reported in Healthcare IT News.
The authors cite several reasons for the failures, similar to the points I have presented in past EMR Straight Talk posts. Among the major conclusions reported were the following:
- While secondary work like audit, research, and billing may be made more efficient by EHRs, primary clinical work is often made less efficient;
- The larger the project, the more likely it is to fail; and
- EHRs do not adequately capture the messiness and unpredictability of the real world.
In other words, legacy EHRs do not benefit physicians, but rather force them to change the way they practice medicine. They fail to give them the tools and flexibility to solve real world problems and to effectively deal with the realities of day-to-day practice. Legacy EHRs “straight-jacket” physicians—requiring them to point-and-click their way through the documentation of patient exams, produce robotic notes, shift their focus away from the patient, and decrease productivity. They do not distinguish the needs of primary care from those of specialists. It is no surprise that implementations fail, and that high-volume specialty practices face the greatest risk.
Like me, however, the authors are not anti-EHR. They realize the need for new strategies and suggest encompassing “imagination and flexibility to overcome the inherent limitations [of existing EHRs].” As readers of EMR Straight Talk know, I have been a proponent of this approach to addressing the needs of high performance physicians. Based on the unparalleled success that our company’s hybrid EMR has in making physicians digital, efficient, and able to provide better patient care, I am sharing our action plan with the EHR vendor community:
- Adopt a laser-like focus on the needs of physicians.
- Invest precious R&D dollars in developing those software features that digitize the medical practice and automate routine clinical processes—those that, in the paper world, create intractable workflow bottlenecks and sub-optimal patient care.
- Convert paper charts to efficient digital, shareable, and portable formats.
- Address the need for speed—count the number of clicks required to accomplish basic tasks and cut it in half. Measure the amount of mouse movement it takes to do the same tasks and reduce that by half.
- Allocate 75% of your programming budget to features that the support and implementation teams want—if it makes a support technician or implementation specialist happy, it will no doubt make clients happy.
- Assure customers’ success—move on to the next implementation only after the current implementation is deemed a success by the client (no matter how much Wall Street or your investors are breathing down your neck for revenue growth).
- Implement an ‘open checkbook’ policy for your support department to hire as many employees as it takes to please your clients—happy clients are your best marketing.
- Hire only ETPs (“eager-to-please” employees) who will always go out of their way to please clients.
If we address the fundamental problems inherent in legacy EHRs and focus on the needs of physicians, adoption will flourish and meeting the goals of the other stakeholders—patients, government, payers, and vendors—will naturally follow.
Finally Talking About What Matters!
Finally, the EHR conversation has shifted to the products. Questions about the efficacy of EHRs are not new, but the stimulus legislation diverted attention from the technology to the EHR incentives. Initially, the discussion was about CCHIT certification, and then it moved on to “meaningful use.” Now, the conversation is focusing again on the EHRs—with an explosion in the number of blogs and publications discussing implementation issues, EHR experience, and concerns about existing technology.
In April, David Blumenthal, M.D., conceded in his New England Journal of Medicine article that “there are significant barriers to [even basic EHR] adoption and use: their substantial cost . . . and the technical and logistic challenges involved in installing, maintaining, and updating them.” He subsequently acknowledged, in remarks to the Agency for Healthcare Research and Quality, that “an enormous amount of research will be needed to determine the effectiveness of health information technology,” and charged President Obama’s newly appointed Chief Technology Officer with soliciting advice from providers to determine what works and what doesn’t.
Just within the last few weeks, the volume and intensity of concerns about legacy EHR technology have escalated. Here’s a small sample of what they are saying:
- Postings on the government’s blog forced the HIT Standards Committee to conclude that there is “substantial concern about the state of the EHR”; “We are not building on a firm legacy of success”; and “Physicians are not overwhelmingly satisfied with existing products.”
- MGMA’s letter to Dr. Blumenthal recognized the need for “appropriate and cost-efficient products” and encouraged “deployment of . . . alternative EHR software product[s]” in recognition of marketplace failures.
- David C. Kibbe, M.D., Senior Advisor, American Academy of Family Physicians, and Brian Klepper, healthcare analyst and consultant, suggest that “it’s become PC to ask tough question about EHRs, quality, and health care costs.”
- Senator Chuck Grassley sent a letter to each of 10 EHR vendors asking them to report complaints from customers (i.e., providers) and patients regarding difficulties encountered with HIT.
- University of Pennsylvania Professor Ross Koppel, Ph.D., believes that the federal government should have used the stimulus money to develop “more usable and more responsible software” rather than relying on outdated technology.
- A Wall Street Journal blog, entitled “Safety Guru: ‘Health IT Is Harder Than It Looks’,” relays the concerns of Robert Wachter, M.D., Professor and Chairman of the Department of Medicine, University of California, San Francisco.
- In a response to the WSJ blog, a physician argues that EHR programmers created an unnecessary level of complexity that slows physicians down and that the designers wrongly assume that physicians should “change their medical processes” to make computerization successful.
Now is the time to revisit the software. An efficient healthcare system requires efficient EHR technology. Recognizing the limitations of legacy technology is an important first step—improving the software to ensure that it is widely adoptable by all physicians should be the ultimate goal.
RFP: Relevant For Productivity?
Identifying the right EHR for a practice has always been difficult—there are so many choices; there is no objective information about competing products; you have to rely on vendor-identified references; and there is an abundance of misinformation about what is (or is not) required by the government. To sort out this information, consultants and practices often rely on the well-known acronym RFP—Request for Proposal—even though the RFP process is flawed.
The big problem with RFPs is that they emphasize the wrong criteria. They yield information about product features and functionality, but not usability and impact on productivity. It’s like buying a car with a full set of luxury options, only to realize later that it tops out at 40 miles per hour. What you didn’t consider is “usability.” EHR failure is tied directly to the impact on physician productivity, yet not one of the last 10 RFPs I’ve received—each containing 100–200 questions—has even mentioned productivity. In fact, by their very nature, RFPs cannot evaluate the characteristics most critical to successful adoption because there is no way to objectively measure things like productivity, efficiency, and usability in a written format. This is why practices using RFPs still end up as part of the 50% EHR-adoption failure statistics.
RFPs provide detailed information about product features and functionality; however, here’s what you can’t learn from even the most comprehensive RFP:
- How long it takes a physician to use the features to accomplish routine clinical tasks—for example, write a prescription, review a chart, or send a message.
- What the net effect on productivity will be—during implementation phase and ongoing.
- What the likelihood is of receiving government incentives—i.e., your ability to use the EHR as required.
- How great the failure rate/number of dissatisfied clients is—from de-installations to clients no longer using the software—particularly in your specialty and practice size.
- What percentage of customers is not using the EHR fully—e.g., still dictating exam notes and transcribing.
To obtain this critical information, practices must take control of the competitive analysis process. Do your own benchmarking of the number of clicks and time required to accomplish a few simple tasks with each of the EHRs under consideration. To estimate the value of the impact on productivity, input the time difference per exam into the productivity calculator. The insights gathered regarding the comparative merits of EHR products will be infinitely more valuable than the information received in response to a 20-page RFP.
Instead of relying solely on an RFP, use a stopwatch to evaluate and compare EHRs. If you would like a stopwatch, just e-mail your name and address to stopwatch@srssoft.com and I will send you a complimentary one.
Government Has Heard Tales of EHR Woe—What Will They Do Now?
Physicians and administrators delivered a strong message to President Obama’s Chief Technology Officer (Aneesh Chopra) and the HIT Standards Committee in comments posted on the government’s blog. These comments make it clear: Traditional EHRs—the technology on which the government is planning to spend $36 billion—do not work for the majority of private practice physicians. Overwhelmingly (57 out of 60), blog contributors reported negative experiences with traditional EHRs, and not one private practicing physician detailed a positive story about his or her experience with a traditional EHR. I also sent Mr. Chopra a personal letter expressing my own concerns.
You gave your feedback and the government heard you loud and clear, but they are still not addressing the fundamental barrier to successful EHR adoption—the EHR products themselves. Our Vice President of Government Affairs, Lynn Scheps, attended the HIT Standards Committee meeting in Washington today. She reports that the Implementation Workgroup:
- acknowledged “substantial concern about the state of EHRs;”
- recognized that “we are not building on a firm legacy of success;”
- questioned whether “complex solutions are the best answer to complex problems;”
- and suggested that “thoughtful simplicity” can address complex issues.
Despite these conclusions, the government is still failing to see the forest for the trees. They are continuing to develop complex standards without requiring major changes to the underlying structure of the EHR products themselves. Without resolving the disconnect between the EHRs that incorporate these standards and the adoptability of these EHRs, we will neither achieve “meaningful use,” nor will we meet the government’s policy goals.
You can still post comments on the government’s blog*—it will remain open until December 1 due to the level of interest and the valuable insights provided.
*Start your comment with “In reference to Implementation Experience”
EHR Realities: From Your Mouth to Government Ears
Over my years in business, I’ve received the usual pieces of advice. One is “Be careful what you ask for; you just might get it.” Another is “Never ask a question to which you don’t already know the answer.” Luckily, no one gave that advice to the government before it launched the Federal Advisory Committee (FACA) Blog last week. The result is that the government is getting plenty of the direct, honest feedback that they asked for, but the answers are not what they expected. And that’s a good thing.
The decision-makers are hearing the voice of the physician and they fear that many will opt out of participation. Consequently, the HIT Standards Committee is soliciting “real-world” EHR implementation stories—they held a public hearing and launched the FACA blog/website. I suspect that they anticipated hearing successful EHR stories and practical suggestions about how to facilitate widespread adoption. Instead, they got an onslaught of disparaging comments that document failed implementations and the perils of productivity-sapping traditional EHRs.
The following comments are representative of the feedback the blog is eliciting:
“The primary benefit to our organization has been the ability to exchange patient information among our 6 offices, as well as general communication within the organization. The negative has been a drop in physician productivity of 20-30%, commensurate with published studies. This has occurred in spite of extensive use of templates and speech recognition and is unlikely to improve in the near future. Furthermore, there is no evidence that there has been any improvement in patient care.”
- F. Ray Nickel, M.D., 12-physician orthopaedic group that implemented a traditional EMR in 2007
“I have had the “opportunity” to use three different EHR systems (all from implementation) at my last job. All of them had huge gaps, especially as a specialist. I found that I needed an extra 5 hours per week to finish documentation. And on top of that, my productivity permanently dropped. There were some benefits, but all on the retrieval side. On the data acquisition side, things were slowed dramatically. Also, patients were unhappy that I was spending more time on the computer than looking at them.”
- Theodore Curtis, M.D., ophthalmologist
“I’m all for using EMRs meaningfully, and second, I’m all for rewarding physicians! However, I believe (as many do) that our current crop of EMRs are far from perfect and I have to question whether we could spend that $36 billion a better way than by rewarding mediocre vendors whose products are poorly adopted and poorly used (see the National Research Council’s recent report: http://books.nap.edu/openbook.php?record_id=12572&page=R1).”
- Lyle Berkowitz, M.D.
“Does making the physician the data entry worker (the slowest and lowest paying job in an office) make sense when by 2025, there will be 200,000+ shortage of health care providers?”
- Jeff Moody, M.D.
“I do orthopedics in a large, multi-specialty group. We have been on Excellian (a version of Epic) for three years. It adds 45-60 minutes per half day of clinic patients. As a specialist, I found little good for me in this system, but many frustrations and slow-downs. For my patients, the EMR is marginal (may help or hinder them), but for me the electronic record system is inefficient and hateful!”
- Scott Lagaard
There is still time to post a comment* documenting your experience and/or suggestions. The blog will accept EHR implementation comments through mid-November, when they will be summarized for presentation at the November 19 Standards Committee meeting.
Although this may not have been the input the committee was expecting, I hope they will value the insights offered and use them to truly facilitate widespread EHR adoption.
*To post a comment, click here, scroll down to “Post a comment,” and type in the CAPTCHA Code (the phrase in the box at the bottom.)
