Healthcare Reform: Get Ready for the Crush!

Against what seemed to be insurmountable odds, President Obama has signed a healthcare reform bill. While the full impact of the bill won’t be known for a while, two things are already clear about this legislation’s effect on physicians. There will be a sharp increase in demand for their services, and they will get paid less for the services they provide—making physician productivity vital.

By 2014, all Americans will be required to have health insurance. A whopping 32 million people will be added to the rolls of private health insurance plans over the next few years with the help of government premium subsidies. Because these people have not had health insurance in the past and many have medical problems for which they have not received treatment, they can be expected to seek care in greater-than-average numbers. Compounding this demand will be the seismic shift in demographics caused by the aging of the 79 million baby boomers, the first of whom turn 65 next year. Their naturally increasing demands for medical care will further stress our healthcare delivery system. Given the current, and growing, physician shortage, physicians will be deluged with patients.

With a projected cost of $938 billion, much of the funding for the legislation will come from cuts to Medicare, which will include payment reform—a euphemism for reduced payments for the services provided by physicians.

Physician productivity has always been important, but the healthcare reform legislation has made it critical. To meet the crush of demand for care, and to grow—or even maintain—their current incomes, physicians will have to see a greater number of patients and do so more efficiently. Now—more than ever—it is important for physicians to invest in software that is physician focused and designed with physicians’ workflows in mind, to ensure that it will increase, rather than decrease, their productivity.

Reminder: to find out what your time is worth, try the physician productivity calculator.

MGMA Confirms Productivity Loss with Government’s EMR Program

What struck me at last week’s annual meeting of HIMSS (Health Information and Management Systems Society) was the conspicuous absence of conversation about the effect of the ARRA legislation on physician productivity—there was hardly a mention of the subject throughout the conference. Jeffrey Belden, M.D., of the HIMSS Usability Taskforce, did point out that documenting patient exams in an EMR takes 10 times as long as documenting by dictation, but offered no solution to that problem. Admittedly, the audience contained few, if any, physicians. However, once again, it struck me that physician productivity was the elephant in the room—the topic that no one was discussing, even though physicians are the very people upon whom the success of the program is so dependent.

I arrived home to the release of the results of a new MGMA study (conducted last month), which concluded that practices expect that the operational changes required to meet the proposed meaningful use criteria will cause a significant decrease in productivity. Nearly 68% of the respondents anticipate such a decrease, with 31% projecting that the decrease would exceed 10%—and this was likely based on only the impact of Stage 1 meaningful use criteria.

This productivity loss is what I described in last week’s EMR Straight Talk post, where ARRA meaningful use requirements compound the reduction in productivity that is already associated with the “point-and-click” EMRs themselves. Before ARRA, physicians estimated that traditional EMRs reduced their productivity by between 20% and 40%, as documented in testimonials posted on the Government’s FACA blog and included in the Voice of the Physician Petition. Others are speaking out about this issue as well; Paul Roemer reported that his cardiologist puts the productivity loss at 30%, due to the amount of time that he “wastes” performing clerical—i.e., data entry—tasks. (Read his comments in “Healthcare IT, How Good is Your Strategy: A Scathing Rebuke of EHR.”) Added together, this means that physicians face a 40% reduction in productivity at the outset. Imagine what will happen to productivity when the more stringent Stage 2 and 3 meaningful use criteria are implemented!

The conclusion is clear. Physicians should not be considering EHR adoption for the incentive money; they should be looking at what will help them address their business and patient-care needs. The HIMSS keynote address by chairman Barry Chaiken, M.D., charged the EMR industry with “creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them.” Systems like that already exist—they just don’t interest the government, which appears to be more interested in data collection than EHR adoption.

Specialists: Square Pegs in the Government’s Round EHR Holes?

It has been abundantly clear to me that the government’s EHR program is not relevant for specialists and other high-volume physicians. It was evident from the outset that specialists were never the focus of the legislation, but recent program-funding announcements dispel—once and for all—any doubts about the government’s intentions in this regard. Furthermore, the type of EHRs that are designed to meet the government’s criteria are not responsive to the particular needs of specialist physicians. The comments I continue to receive, and those posted elsewhere, are adamant on that point.

As a result, the Stimulus Legislation poses overwhelming challenges for specialists—challenges that outweigh any potential returns. This is hardly surprising given the lack of input from specialists in the decision-making process. With only one or two exceptions, the physicians involved are all primary-care or informatics experts, not specialists. It was not until October that the question of specialists was even discussed, and so the “meaningful use” criteria that emerged don’t fit the services that specialists routinely provide, nor do they fit the way specialists routinely practice medicine, at least not without major workflow disruptions.

The focus on primary care is indisputable. Look at the programs that have been announced and funded in just the last two weeks:

  • February 2, 2010: ONC will survey 1,700 patients in 84 primary-care practices because it recognizes “an evidence gap about patients’ preferences and perceptions of delivery of health care services by providers who have adopted EHR systems.” (Notice in the Federal Register)
  • February 12, 2010: The Department of Health and Human Services (HHS) announced $375 million in funding for Regional Extension Centers (RECs), which will “provide outreach and support services to at least 100,000 primary-care providers and hospitals within 2 years.” In describing the RECs, David Blumenthal stated, “Primary-care providers in small practices provide the great majority of services in the U.S. but have limited resources to implement, meaningfully use, and maintain EHR systems. On-site technical assistance for these priority-primary care providers will be a key service offered by the RECs.”

But the biggest obstacle for specialists remains the traditional EHR products themselves—the challenges posed by the government program only compound the fact that these EHRs are fundamentally so difficult for many physicians to use. Designed for primary-care practices, their success has been limited to that arena. Traditional EHRs are built around the creation of exam notes, not around workflow and physician productivity. The highly leveraged nature of specialists’ practices—where office visits lead to surgeries and other procedures—makes their economics highly sensitive to even small negative impacts on productivity. In addition, their high patient volumes make workflow-focused software critical, and note-focused software unusable. For example, a 10% reduction in productivity for the average specialist would result in an annual revenue loss of over $100,000. (Use our physician productivity calculator to estimate the cost to your own practice.) As a result, there are a very few large specialty practices that have successfully and fully adopted a traditional EHR.

The government should be up front about their interests and acknowledge their focus on primary care. Until they devote the same kind of resources to finding out what works in medical specialty practices, they should just leave the specialists out of the program—exempting them from both incentives and penalties.

Government EHR Program: Unintended Consequences (continued)

Last week’s EMR Straight Talk, “Government EHR Program: Potentially Harmful Unintended Consequences,” seems to have struck a nerve with readers—based on the number, source, and intensity of the comments. The elevated level of concern is palpable. What I find rewarding is that blogs like EMR Straight Talk are creating a community of physicians who find support for their concerns—concerns that they might have thought were unique to themselves. Several of last week’s comments came from physicians who are not even on our mailing list, which means that their colleagues are sharing the blog, seeking to build support for their beliefs. Most of the comments were submitted by specialist physicians who are getting our message and beginning to speak up about why they do not consider the government’s EHR program relevant for their practices.

Those commenting identified several additional unintended consequences and voiced other concerns, including:

  • Dissatisfaction with templates and the utility of the notes they generate;
  • Failure of the government program to consider the needs of providers;
  • Effect of traditional EHRs on physician productivity;
  • Failure of physician organizations to speak out on behalf of their constituents; and
  • Difficulty of finding the right EHR for a practice.

An interesting comment came from Paul Roemer, who directed concerned readers to his post on HealthsystemCIO.com, in which he suggests that the “meaningful use” dates will be pushed back. He maintains: “Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.” His contention is that very few providers will be ready or able to take advantage of the incentives, including those who already have implemented a traditional, point-and-click EHR.

What do you think the government should do with its program that is clearly meeting significant and vocal resistance—particularly among specialists and other high-volume physicians? Submit your comments below, and let’s keep the conversation going.

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.

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.