100% EHR Success – A Clinical Approach

Last week’s EMR Straight Talk post, “Are EHRs Being Oversold,” hit a nerve, judging by the number of readers and the volume and intensity of comments submitted by physicians. Sadly, for every one of the physicians who took the time to write, there are scores of others enduring similar experiences. The following excerpts from their comments are reflective of their frustrations:

  • We are a year into [EHR] implementation and it has been horrible and costly. What little efficiencies gained have been lost to a decrease in productivity.
  • I now require a scribe to maintain the [same] patient flow that was seen four years ago we began using the system.
  • The trouble with most EMRs is the horrible user interfaces that are designed by committees who have no concept of ease of use for ophthalmologists.
  • The programs are user unfriendly in the extreme, cumbersome and inflexible. The learning curve is seriously long and even when mastered takes a terrific amount of time away from the patient.
  • The joy-killer was encountering the endless barriers to putting my own ideas to work.
  • Training is lengthy, expensive, and markedly disruptive in an office.

Every one of these stories breaks my heart as a staunch EHR proponent—particularly since the situations could have been easily avoided.

The Root of the Problem

The problem lies in the EHR selection process. When it comes to dispensing medications, for example, no physician prescribes without knowing the success rate for that particular drug for that particular type of patient and problem being addressed. Yet, typically, physicians do not make EHR purchase decisions in the same way that they make clinical decisions—using empirical evidence and data to predict outcomes.

I’d wager that for each of the disillusioned physicians above, the EHR selection process was nearly identical:

  1. The group chose 5 to 7 vendors for consideration;
  2. Each vendor demoed their product in front of an EHR selection committee whose task was to narrow down the field to 2 or 3 finalists;
  3. The finalists performed one or more demos to a wider group of physicians and staff;
  4. The vendors each provided 2 or 3 practices as references, with specific contact names;
  5. One or two physicians and staff members spent a day visiting one reference site for each of the vendor finalists; and
  6. They selected an EHR.

Why does such an exhaustive and time-consuming selection process so often lead to failed EHR implementations?

Preventing an EHR Failure in Your Practice

To prevent an EHR failure in your practice, the flawed selection process must be altered. The first thing to understand is that the rosy experience of one or two handpicked vendor references will not guarantee a similar experience for you and your colleagues. If a vendor has sold its EHR to 100 practices and has as few as 5 successful implementations, you will be referred to one of these 5 practices. A visit to 1 or 2 of these 5 successful practices may leave you with a warm and fuzzy feeling and the expectation that, because they were successful, your success is virtually assured. In this case, however, your real probability of success would only be 5%.

Separating the Wheat from the Chaff

So how do you quickly eliminate vendors with lackluster success records before you and your staff waste hours watching slick sales demonstrations of sexy software with “must-have” features? Separating the wheat from the chaff is simple—just ask all your initial set of EHR vendors for lots of references. If a vendor cannot produce at least 2 references for each year they have been in business, run the other way. Do not accept any excuses for being unable to provide you with the number of references that you seek. (A common excuse is that the vendor wishes to protect the privacy of its clients.) If they had lots of references, they would give them to you in a heartbeat—happy customers are always willing to show their successes to others.

Many of the initial vendors chosen will not be able to produce a satisfactory number of references. This should narrow down the number left for you to consider, and it will save a tremendous amount of valuable physician and staff time.

Statistically Significant Reference Checking

At this point, your list of vendors will likely include just the one or two that have provided you with a meaningful reference list. You may have to accept the bias created by the fact that the references are carefully handpicked by the vendor(s), but it is imperative that you do not limit your inquiries to the specific physicians identified by the vendor. Typically, these are the practice administrator and one or two physicians who had spearheaded the EHR purchase for the practice; as a matter of pride, they are more likely to paint a rosy picture of the EHR than to acknowledge its shortcomings. The only way to avoid this trap is to speak with other physicians at the reference practices. This is easy to do. When you get the reference list from an EHR vendor, ask them to include the practice websites, then randomly choose physicians to call from the physicians’ bio pages. These physician-to-physician calls should be short (only 10 minutes each) and you should ask specific questions about cost, efficiency, and number of patients seen.

  1. When did you install your EMR?
  2. How long was the installation/implementation process?
  3. How would you describe the installation/implementation process?
  4. Was the system as user friendly as the demonstration by the salesperson?
  5. How many patients per hour/per day did you (and your partners) see before the installation/implementation of your EMR?
  6. How many did you see after?
  7. Approximately how much more time do you devote to entering exam data into your EMR now compared to how you documented exams before you began using an EMR?
  8. How do you like the quality of the EMR-generated exam notes?
  9. Have you had to hire scribes to enter data for you? If so, how many and what is their annual cost?
  10. Has your EMR completely eliminated the paper charts in your practice?
  11. Given your practice’s experience with your EMR, would you recommend it to a similar practice?

How much of your time should this type of random reference checking take? Not much! Ten 10-minute calls (less than 2 hours of time) to randomly chosen physicians will yield more valuable data on your chances of success than having a slew of vendors demo their products to your doctors and staff for hours on end. Only after having conducted the due diligence described above will you be able to derive real value from spending your time seeing demos—because you will only be seeing demos of the one or two EHRs that you now know are likely to deliver success.

Are EHRs Being Oversold?

I am a firm believer in the tremendous value that the right EHR can deliver to physicians, so the historic dissatisfaction with the EHR industry—as reported in studies and anecdotal conversations—has long disturbed me. The alarming intensity of this dissatisfaction was brought home by visitors to my company’s booth during the recent AAO (American Academy of Ophthalmology) meeting.

I was truly appalled by the abject frustration and anger expressed by numerous physicians about their EHRs. One visitor described his experience by saying, “It has taken the joy out of practicing medicine.” Another said that he felt like he should put a picture of his face on the back of his head so that his patients could see him—because he was forced to focus on the computer and enter data while the patient provided information. Physicians universally complained about the “productivity-killing” impact.

From AAO - Are EHRs Being Oversold?Why is this so? I know there are good EHR products in the market that physicians enjoy using and that enhance, rather than reduce, their productivity. Why are physicians not more successful in finding these?

The answer is that EHRs are being oversold. There are many EHRs that are marvels of software, capable of doing incredible things, but the selection process that physicians typically employ is flawed, and the sales process capitalizes on this shortcoming. The salesperson dazzles them with a demo, or they take prospective purchasers to see a physician—typically just one or two—who adeptly uses the software. This creates a false sense of ease-of-use, and the physician prospect leaves the site visit expecting that he or she will be able to use the EHR just as successfully. But not all physicians are alike—they may all be very intelligent and have tremendous medical expertise, but they are not all equal in technological inclination or skills. Their success—or lack thereof—with a particular EHR will vary significantly.

This brings us back to the importance of doing due diligence—something I have talked about before. Call and/or visit a variety of physicians who represent a wide spectrum of proficiency. Go to the reference practice’s website and select physicians on your own—don’t rely on the vendor’s selection. Ask the kind of questions listed in the last EMR Straight Talk. This is the only way to increase the odds of a successful EHR experience, and to avoid making a painful and costly mistake.

EHRs: AAO Keeps Its Eye on the Ball

I’ve written frequently about the unique needs of specialists and how these have been overlooked by the government and by EHR vendors. Since many ophthalmologists are heading off this week to the AAO (American Academy of Ophthalmology) Annual Meeting in Orlando, I thought it appropriate to comment on the proactive advocacy and advisory role that this particular professional society has adopted on behalf of its members, and to encourage other academies to step up their efforts similarly.

EHRs: AAO Keeps Its Eye on the BallAAO has been quite active on the meaningful use front. This week’s HIT Policy Committee’s Meaningful Use Workgroup meeting focused on how make meaningful use more meaningful for specialists in Stage 3. AAO was one of only two specialty societies represented in the public comments at the end of the meeting—the Academy’s representative pleaded that measures irrelevant to ophthalmology be replaced with those that would add value for these specialists, and offered the Academy’s assistance to accomplish this.

In addition to providing its members with otherwise unavailable, ophthalmology-specific direction on how to meet meaningful use, AAO has also offered much-needed guidance regarding the selection of an appropriate EHR for ophthalmologists—meaningful use aside. Recognizing that their unique specialty-specific workflow and data needs are not effectively addressed by most EHRs—because of the typical primary-care focus—AAO charged its Medical Information Technology Committee with the identification of a set of ophthalmology-relevant EHR specifications. A group of authors led by Michael Chiang, M.D., identified a set of features and attributes that ophthalmologists would find particularly valuable, and published their recommendations in an article titled “Special Requirements for Electronic Health Record Systems in Ophthalmology.”

While features and functionality are important, feedback from colleagues who actually use the EHRs is even more critical. The advice that AAO has given its members on how to make the most out of site visits will serve all physicians well, regardless of their specialty, and I am therefore sharing it with you below. It is reprinted from the publication “Electronic Medical Records: A Guide to EMR Selection, Implementation, and Incentives.”

ASK COLLEAGUES THE RIGHT QUESTIONS:

  1. When did you install your EMR?
  2. How long was the installation/implementation process?
  3. How would you describe the installation/implementation process?
  4. Was the system as user-friendly as the demonstration by the salesperson?
  5. How many patients per hour/per day did you (and your partners) see before the installation/implementation of your EMR?
  6. How many did you see after?
  7. Approximately how much more time do you devote to entering exam data into your EMR now compared to how you documented exams before you began using an EMR?
  8. How do you like the quality of the EMR-generated exam notes?
  9. Have you had to hire scribes to enter data for you? If so, how many and what is their annual cost?
  10. Has your EMR completely eliminated the paper charts in your practice?
  11. Given your practice’s experience with your EMR, would you recommend it to a similar practice?

EHRs are here to stay, and will play an increasingly important role in medical practices. A major investment, EHRs can dramatically impact practice operations and productivity—positively or negatively. It is my hope that, like AAO, the medical academies will use their clout and speak out more aggressively to protect the interests of their members.

Wall Street and EHR Customer Satisfaction

I was recently reviewing the results of the KLAS 2011 mid-year survey, in which EHR users rated their respective vendors and products. Having spent some time on Wall Street early in my career, I could not help but notice a striking correlation between customer satisfaction and company ownership. The three top-ranked EHR companies—and five of the six top-rated companies—are privately held, while the bottom three—and eight of the nine lowest ranked companies—are publicly traded.

At first, I attributed this finding to sheer coincidence, but as I thought more about it, I realized that the correlation, while striking, is not surprising. Beholden to Wall Street, publicly traded companies seek to satisfy investors with short-term profits. They may be motivated to cut costs to generate higher net income for investors, and their ability to reinvest in ways that will promote future growth can be constrained by these outside interests. One common way to manage costs is to locate support offshore in call centers 8,000 miles away, where technicians read from a script in attempting to answer customers’ questions—cost-saving for sure, but detrimental to customer satisfaction.

Privately held companies, on the other hand, are accountable first and foremost to their clients. Free to take a long-term view of their business, they invest heavily in research and development. They also invest in their technical support teams—funding adequate staffing levels and ensuring that they receive ongoing training to keep them at the forefront of technology. The result is often lower turnover and a more experienced, higher-quality staff, which in turn results in superior customer service and happy clients.

EHR Meaningful Use Not Being Embraced by Commercial Carriers

This time last year—amidst all the hoopla surrounding the finalization of the Stage 1 meaningful use requirements—it appeared that the commercial insurance companies were ready to jump on the meaningful use bandwagon and follow the government’s lead. What has happened to their interest? I have not read about the development of such programs since the initial announcement of the carriers’ intentions.

Aetna promised to reward the achievement of specific quality goals, and United HealthGroup, WellPoint, and Highmark (a Blue Cross Blue Shield program) said they were going to make meeting meaningful use criteria the basis for rewards in their programs. The general consensus was that we could expect many more carriers to align their payment systems with the EHR incentive program—but this has not happened.

What caused the private sector to abandon the rush to meaningful use? I believe that the following are the factors preventing private payers from embracing meaningful use and incorporating it into their reimbursement schemes:

  • CMS essentially acknowledges that the clinical quality measure data being collected through meaningful use will be of no real value. We have heard over and over, in response to criticisms levied, that for Stage 1 this is strictly a reporting exercise. Unlike PQRS, there are no thresholds to meet, physicians are being asked to report on measures not relevant to their practice, and no one’s medical practice is being judged on the numbers submitted.
  • Private carriers cannot afford failure. They would like nothing more than to be able to use proven quality measures to drive quality and efficiency so that they can keep their premiums competitive and gain market share. But the evidence is not there yet.
  • There has been a great deal of conversation about whether physicians are being pushed too hard and too fast. Providers are challenged by an overwhelming number of looming IT requirements. Registration for the EHR incentives is moving forward, but attestation numbers and incentive payments are lagging behind expectations.
  • Insurance carriers also have a lot on their plates—health care reform, insurance exchanges, maintaining the required loss ratio, ICD-10, etc. Meaningful use is taking a back seat to other priorities.

Rome Wasn’t Built in a Day

In my last EMR Straight Talk post (Stage 2 Clinical Quality Measures—More Is Not Better), I maintained that simply adding a large number of new quality measures without addressing the underlying flaws in the reporting process will do little to advance the program towards its goals. So I was very interested in reading Joseph Goedert’s blog the following week in Health Data Management: “Why Must CMS Overreach on Rules?”

In discussing the proposed rule regarding Accountable Care Organizations (ACOs), Joe makes a similar argument to mine. He questions CMS’s proposal that, to share in an ACO’s savings, providers would have to report on 65 quality measures—including 28 new measures—when CMS will not even be ready in 2012 to electronically accept the considerably smaller number of quality measures associated with meaningful use.

In both cases, CMS is trying desperately to accomplish a long-term vision, albeit a noble one, in too short a timeframe. While formulating its proposal for Stage 2 meaningful use, the HIT Policy Committee had several intense discussions about the trade-off between (1) aggressively moving toward the end goal and losing people along the way because they were overwhelmed and feared failure, and (2) accepting a slower pace, but with a greater chance of success. The foundation of the programs have to be solid, or real progress will not be achieved.

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Reader’s Correction/Clarification:

In my EMR Straight Talk post on August 10, (“HIE’s and Information Sharing—Physicians Feel the Pressure”), I incorrectly stated that without membership in NYU’s UPN (University Physicians Network), “physicians do not have access to the group’s favorably negotiated reimbursement rates.” I received a comment from Robert Goff, Executive Director of NYU’s UPN, stating that “UPN does not negotiate with any payer or health plan outside of fully compliant shared risk arrangements,” and that the requirement regarding physician information technology “is part of a broad initiative to promote enhanced quality and the delivery of more efficient health care.”

I apologize for the misstatement.

Stage 2 Clinical Quality Measures—More Is Not Better

Serious time and effort is being devoted to the development of the clinical quality measure (CQM) reporting requirement for Stage 2 of meaningful use, with the intention of accelerating progress toward the program’s end goals. Sadly, however, the old joke keeps coming to mind about an airplane pilot who announces to his passengers that he has good news and bad news. The bad news is that he has no idea where they are, but the good news is that they are making great time!

Moving forward in Stage 2 without first addressing the fundamental flaws and omissions that plague Stage 1 is not the right approach. CMS has acknowledged that the CQM reporting requirement in Stage 1 is no more than that—a reporting requirement meant to get physicians comfortable with the process of reporting. CMS is under no illusions that the data collected will be meaningful as a measure of the level or quality of care being provided. Many physicians will be reporting on problems for which they are not treating the patients, which means that measure numerators will be zero (or very low) and that duplicate data will be submitted by different physicians for the same patients for the same conditions, which will result in an underestimation of the true care being delivered.

The Stage 2 recommendations for CQM reporting that the HIT Policy Committee has forwarded to CMS significantly expand on the Stage 1 measures in an attempt to address a broader set of factors that affect quality, as well as to be relevant to a wider set of physicians, including specialists. These are important goals, but premature. The model that was created—shown in this graphic—requires the addition of an extensive “library” of measures for each of the 6 menu “domains”.

Adding a large number of measures will be challenging on a practical front—it will involve development and testing by specialty societies and NQF, implementation by EHR vendors, training for providers, etc.—but more importantly, it does not address the basic issues related to the value of the data submitted. The problems identified above remain, no target thresholds exist, and no meaningful baseline data will be established to monitor progress over time. This is clearly a case where more is not better.