EMR Ratings: A KLAS Act (Part 2)

Last week, I discussed the merits of the new KLAS Performance Report that categorizes EMR ratings based upon practice specialty. The industry has responded very positively to this major step forward, and I suspect that KLAS has received many requests for access to the publication.

One of the obstacles that KLAS faced in reporting by specialty was a lack of sufficient data in many of the categories and for many of the vendors. This data limitation leads me to several initial observations and raises important questions:

  • While there are 27 vendors rated in the primary-care section and 20 in family practice, there are only 2 vendors in ophthalmology, 3 in orthopaedics, and 5 in cardiology with sufficient volume to merit inclusion. Why is that? EMR vendors have been marketing to the specialty physicians for well over a decade. Does this confirm that traditional EMRs have only had real traction in primary care after all these years?
  • A disclaimer by KLAS says that vendors may be excluded from a category due to insufficient data points, yet I know from my own company’s sales experience that there are vendors who claim a large number of installs in specialty practices. Why are these practices not included in the survey results? Did they de-install their EMR? Did the implementation fail, or are the providers not really using the EMR so they chose not to respond to KLAS? Did vendors not supply KLAS with a sufficient number of specialists due to such problems? Whatever the reasons, the lack of responses from specialists is not surprising, given the dearth of specialists’ testimonials or EMR success stories on vendor websites and on industry and government blogs.
  • Some of the vendors that are not rated highly by clients in the specialty categories received significantly better KLAS ratings from their primary-care clients. This data validates the tremendous difference between the EMR needs of specialists and those of primary-care physicians, as I have discussed in numerous posts. The fact that traditional EMRs are designed to meet the needs of primary-care physicians was a concern echoed by the American Academy of Orthopaedic Surgeons in its EMR Position Statement, which said that the primary-care focus “can limit the utility of EHRs for specialty surgical practice.” Force-fitting an EMR designed for primary care into a specialty practice is what has resulted in the historically high failure rate of EMRs among specialists.

Limitations of the data notwithstanding, one conclusion is inescapable: The KLAS report is a great first step in providing specialists with considerably more information than they had prior to its publication, but the burden still remains on the specialists to do their due diligence to identify an EMR with proven success in their specialty.

EMR Ratings: A KLAS Act

This week, KLAS released its first EMR Performance Report that organizes results according to the specialty of the rating provider. Although the publication of “Ambulatory EMR by Specialty” came on the heels of my posts last week—titled “One Size Does Not Fit All” in EMR Straight Talk and HIStalk—the timing was purely coincidental.

I want to commend Mark Wagner and Kent Gale for taking on this new approach to analyzing and reporting the data they collect. I have had numerous conversations with KLAS on this subject over the years, urging them to report by specialty for all the reasons identified in my posts, and they clearly recognize the value of this type of information. This effort by KLAS was a major undertaking, and the result represents a significant breakthrough in the way the EMR industry provides access to information.

For any specialists looking to adopt an EMR, the KLAS report “Ambulatory EMR by Specialty” is a must-read. It contains information that is vitally important to informed EMR decision-making.

The data raises some interesting questions and implications. In next week’s EMR Straight Talk, I will share some initial observations.

Enterprise EMR: One Size Does Not Fit All

In my recent post on the industry-leading EMR blog HIStalk, I discussed the impossibility of one type of EMR ever meeting the needs of all the disparate types of providers. Among the arguments I presented was that it is impossible for the same EMR product to satisfy both hospitals and private-practice physicians. Enterprise EMRs simply do not work in high-volume ambulatory settings, and it is unrealistic to expect that they would.

Apparently, this hit a nerve, given the passion and intensity of the comments, most of which addressed Epic. (You can read the comments by clicking here.) In response to Peppermint Patty’s claim that “tens of thousands of happy specialists use Epic,” Epic Mythology replied, “The idea that all specialists, or users in general, are happy with Epic is a flat-out lie. My own academic specialty clinic rebelled against Epic’s ambulatory interface as long as we could, and we switched only by force. It destroyed my clinic workflow, and I now see fewer patients while spending longer documenting. . . . I have yet to meet any doctor who really likes Epic.”

There you have it—the basic problem in our industry identified very simply by the argument between Peppermint Patty and Epic Mythology. How do we know who is right? These and several of the other comments beg the question of how a specialist—or any physician—can ferret out the truth about the potential of Epic (or any other enterprise EMR) to satisfy his or her practice’s needs? This is becoming an increasingly critical issue, given the growing pressure hospitals are putting on physicians to adopt the enterprise system by subsidizing the cost. Are physicians who succumb to this pressure getting what is right for their practices?

The following is the comment I added to HIStalk following the initial set of responses to my “Reader’s Write” post:

Judging by the comments to my post, the implementation of enterprise EMRs in ambulatory practices is a major issue confronting physicians. Most of the comments focus on Epic, the dominant player in that market. Peppermint Patty and Epic Mythology sum up the two positions—the former claims that there are many happy users of Epic, while the latter argues the exact opposite. Who is right? And how do we find out for sure? My experience speaking with thousands of physicians over the years supports Epic Mythology’s position—like him, I have not met many specialists satisfied with using enterprise EMR systems in their private practices.

Given the revived interest in EMR purchases, it’s critical for the physician community to know the truth.

Please continue the conversation by commenting on EMR Straight Talk (below) or by joining the dialogue on HIStalk.

Preserving Physician Income in a Low-Margin Environment: EMR Strategy

A frequent concern I hear in my conversations with physicians is that they are challenged by increasingly harsh economic pressures. Healthcare reform, lower—or at best stagnant—reimbursement rates from government and private payers, and the higher proportion of lower-paying Medicare patients are reducing or capping practice revenue. At the same time, overhead costs are escalating unrelentingly, since employees still expect raises and other operating costs continue to rise. While the common perception is that physicians are not businessmen/women, they are in fact running small businesses; and now, more than ever, they need to focus on ways to maintain business viability in light of lower margins.

Physician Income Calculator

The above graph illustrates the economic challenges. Click on it to enter your own practice data and assumptions concerning anticipated growth or decline in reimbursement and expenses, and observe the effect on physician income—the green line. Given that physicians have no control over reimbursement rates, the only way to positively impact that green line is by effecting fundamental changes to practice operations—and the right EMR is critical to this end.

First, it is imperative to significantly reduce overhead—the orange line. Government programs that may, or may not, deliver short-term financial incentives do not address cost structure. What is needed is an EMR that delivers sustainable and significant reductions in the staff-to-physician ratio and more efficient management of all resources—depressing the orange line. Increasing revenue—the blue line—requires increases in physician productivity and patient volume. The challenge here is to wade through EMR marketing hype to identify the EMR that will actually shift the orange line down and the blue and green lines up.

EMR Purchase: Caveat Emptor

Physicians practice evidence-based medicine. They base clinical decisions on evidence gained from scientific research and experience. As patients, this is the source of our confidence in their diagnoses and treatment plans for us. Unfortunately, an alarming number of physicians do not apply evidence-based decision-making to their EMR purchases. This explains the 50–80% EMR failure rate documented in the Milbank Quarterly and cited by the AMA.

Recently, I’ve spoken with several ophthalmology practices that are struggling under the weight of unsuccessful EMR implementations—many of these situations would have been averted by asking the right people the right questions at the right time—before signing the EMR contract. Let me share a few examples of how aggressive due diligence uncovers important facts:

Buyer BewareAn ophthalmology practice purchased an EMR from [Vendor 1] based on its ad stating that nearly 500 ophthalmology practices use a [Vendor 1] product. Had the physicians asked for the names of 10 ophthalmology practices of their size that use this vendor’s EMR, they would have learned—by the lack of response—that most of the 500 practices use the vendor’s practice-management system, not its EMR. Don’t fall prey to deceptive marketing.

Beware of references with vested interests. For example, a physician would never know that the reference for [Vendor 2] has an ownership interest in the vendor’s company. Not surprisingly, the reference physician described the EMR as “excellent.” It was only a subsequent blog comment from another physician in the practice that revealed that, after 3 years, she still schedules 6 fewer patients each day and has hired a skilled technician to assist her, adding $37,500 per year in costs.

Another practice made a visit to [Vendor 3’s] reference site and learned that the physicians in the practice are, in fact, using the EMR. If they had probed further and asked about staffing, however, they would have learned that instead of 8 scribes, this practice now employs 24 scribes to handle the necessary data entry—two for each ophthalmologist (instead of one before the EMR adoption), and one for each optometrist (when the optometrists had never needed any scribes at all before the EMR).

It’s equally important to randomly select physicians to call. Do not limit your conversations to those physicians hand-picked by the vendor—other physicians in the practice will always take calls from colleagues. Ask each physician how many patients he or she sees each day now as opposed to before EMR implementation. Within the same practice that purchased [Vendor 4’s] EMR, physicians using the EMR successfully are those who see only 25 patients per day, while the ones who see 60 patients daily do not use it because of its effect on their productivity.

If you apply the same due diligence and evidence-based decision-making to your EMR search that you do to treating your patients, you will have the information you need to ensure that the EMR you select will be the right EMR for your practice.

EMR Selection: How to Uncover the Truth

Why are a growing number of practices considering replacing their EMR, or even de-installing it altogether? Most likely because they made their purchase based on a checklist of features and a slick demo, rather than on a careful analysis of actual usability. Physicians who are trading in their EMRs have realized that the features that seemed so attractive at the outset are meaningless when physicians don’t use them.

There are two kinds of features: The first are the glitzy bells and whistles that, while impressive in a sales presentation, are too time-consuming and difficult for physicians to use on a regular basis in the course of seeing patients. Such features are the result of sales-driven—rather than physician-focused—software development efforts. These are the features that one can easily check off in a Request for Proposal (RFP), the limitations of which I discussed in another EMR Straight Talk post. The more important features—those that create usability, e.g., speed, ergonomics, a unified desktop, etc.—are much harder to assess without actually using the EMR in a practice environment. Other than by trial, you can only evaluate usability by speaking with actual users, which makes it absolutely critical to make the best use of EMR references. The following are my top ten suggestions for maximizing the value of client references:

1. Take command of the process yourself—do not let the vendor control which practices you visit and with whom you speak.

2. Ask the vendor for—and insist on—more than just a few references to practices in your specialty, along with a significant sample of practices that are a similar size to yours. (In EMR References: Cast a Wider Net, I suggested asking for fifteen.) Unless your practice is located in a very remote area, you should not have to travel a great distance to find a reference site. Be leery of large, national EMR companies that only offer a limited number of references in relation to the number of clients they claim to have.

3. Identify some references on your own by networking with colleagues in your area, at your hospital(s), through professional organizations, or on listservs. Contact these practices directly. You will enhance your chances of getting balanced information if your sources are not limited to the vendor’s hand-picked, successful clients.

4. Involve both administrators and physicians in the site visits. Physicians must get first-hand feedback from other physicians to determine how—and if—the system could be used effectively in their own practice.

5. Make sure your physicians observe the client’s physicians using the EMR. They should speak with more than one physician at the practice to make certain that all, not just one, of the physicians are successfully using the system. Conversations with randomly selected physicians are most likely to yield reliable feedback.

6. Investigate the impact on physician productivity by asking physicians how many patients they saw per day before implementation, how much they had to cut their schedule back during implementation, and how many patients they see currently.

7. Be concerned if the vendor’s representative insists on being involved in every conversation with the reference. People are hesitant to make negative comments in the presence of the vendor for fear of repercussions.

8. Ask questions such as: “What EMR features did you expect to use that you are not using, and why not?” or “How do you document patient visits?” to elicit valuable information.

9. Ask the practice manager and/or physicians if you can call them again if any other questions come to mind. Get e-mail addresses and follow up as needed.

10. Devote a significant amount of time to the process.

Controlling the reference process will increase your chances of a successful EMR adoption. In the absence of EMR reform protections and specialty-specific vendor satisfaction ratings, it is up to you to protect your interests by conducting thorough due diligence.

Browser-Based vs. Client-Server EMRs: Productivity is King

Last week’s blog evoked some spirited comments, to which I will respond collectively. I encourage you to keep this conversation going by continuing to share your thoughts on this clearly hot topic.

First, let me clarify some terminology, so that we are all on the same page. Some responses to last week’s post confused browser-based applications with hosted ones. Any application can be hosted—the server can reside anywhere. However, software that runs by opening a browser (like Internet Explorer) and going to a website cannot possibly deliver the speed and crispness afforded by software installed on a PC.

There is no question that there are some advantages to browser-based applications, as was pointed out by readers. A few of these are indisputable, while others are debatable, but the overarching issue is the two models’ very different effects on physician productivity. Rather than debate the merits and drawbacks of the various alternatives, I refer anyone interested to “The Evolution of the Productivity-Focused EMR User Interface,” a white paper that explores those issues and suggests ways to overcome the respective drawbacks.

No matter how you balance the arguments in favor of one approach or the other, the fact remains: there is an undeniable difference in impact on physician productivity. This is something EMR vendors do not want to discuss and Wall Streeters do not take into account, but physicians need to consider it carefully. I’ve talked about productivity many times because of its critical importance to high-performance physicians, particularly high-volume specialists. (See the EMR Straight Talk posts on healthcare reform and government incentives.) A 30-second productivity differential per patient visit can allow a 3-physician practice to generate an incremental $700,000 in patient revenue over 5 years. For a 30-physician practice, the incremental difference climbs to $7 million.* This impact dwarfs the IT-related savings delivered by browser-based applications.

* These results use the Productivity Calculator to estimate the value of 30 seconds for each physician, assuming: 125 exams/week; 24 exam-room hours/week; 47 weeks worked/year; and revenues of $1.1 million/year.