What Is a Hybrid EMR?

The continued success of hybrid EMR has prompted extensive debate about what actually constitutes one. While the Internet is now filled with discussions about EMRs, the number of conversations regarding hybrid EMRs has exploded. People are always asking me what it is that makes hybrid EMRs work so well and how they are different from traditional (CCHIT-type) EMRs. This is the first in a series of 3 discussions that will address this subject.

A hybrid EMR is a high-performance EMR that is successful in high-performance practices.

In 1997, SRS created the first hybrid EMR, concentrating on performance-driven practices, where high-volume physicians demanded unencumbered productivity. As others have followed our lead, hybrid EMRs continue to be designed with efficiency and speed in mind. This emphasis on performance criteria contrasts sharply with traditional EMRs. As a reading of the CCHIT criteria reveals, traditional EMRs are constructed for lower-volume, primary care practices where speed is not a primary driver.

SRS has built the largest national network of high-performance practices that successfully use an EMR. Our development process is driven by these practices and we work to facilitate the sharing of best practices among them.

In the next segment of the series, I will share my thoughts on a key defining characteristic of high-performance hybrid EMR—high usability.

ePrescribing—A Great First Step

In contrast to the concerns I have expressed in prior posts about the government’s EHR incentives plan, the Medicare ePrescribing program is an example of the appropriate way to reconcile the goals of the government with the needs and motivations of practicing physicians, on whose participation the success of the program depends.

The ePrescribing program should serve as a model for other government plans. It aligns the interests of all parties, delivering the healthcare-reform benefits the government has targeted—interoperability, sharing of data, cost savings, and improved quality of care through reduction of errors and adverse drug interactions—while simultaneously offering added value to physicians. The latter is the missing link in the proposed EMR incentives program.

With the right ePrescribing software, physicians improve practice workflow by using office staff more efficiently and by writing prescriptions in less time. At the same time, they make better-informed Rx decisions, reduce their malpractice exposure, and eliminate repeat patient calls that tie up staff unnecessarily—patient satisfaction increases.  All of these factors lead to increased revenue and greater opportunities for practice growth. In addition to the benefits that accrue to physicians, pharmacies receive accurate, legible scripts that eliminate the need for clarification calls, and insurance companies see fewer claims for multiple-sourced prescriptions. ePrescribing is a win-win-win program for all parties.

Clearly, ePrescribing is inherently less complicated than adoption of a complete EHR. Unlike dealing with all the complexities and nuances of the human condition and its maladies, prescribing drugs electronically is easy because it deals with a finite set of data that is perfectly suited for a digital solution.

A Physician’s Voice

It is one thing for me to describe the limitations of traditional (CCHIT-type) EMRs. After all, I have a vested interest in a hybrid EMR. I have devoted 12 years of my life to developing a type of EMR that reflects the physician’s voice and that offers benefits for workflow and quality of patient care. I could be accused of being biased. I would therefore like to share with you an opinion piece published last week in the New York Times, “The Computer Will See You Now,” in which Dr. Anne Armstrong-Coben, a clinical professor of pediatrics at Columbia, shares her personal experiences with a traditional EMR. This one user has hit the nail on the head when she concludes that “the computer depersonalizes medicine.” Her comments support the conclusions presented in the New England Journal of Medicine article, “Avoiding the Pitfalls of Going Electronic.”

Dr. Armstrong-Coben struggles to keep the computer from interfering with her ability to connect with her patients. “I find myself apologizing often, as I stare at a series of questions and boxes to be clicked on the screen and try to adapt them to the patient sitting before me.” She describes a chart produced by her traditional EMR as “a generic outline, screens filled with clicked boxes.” She recognizes that these charts are incapable of capturing the nuances that are so important to high-quality diagnosis and treatment. Dr. Armstrong-Coben suggests that alternatives like a hybrid EMR might be a better solution.

I maintain that the computer is a wonderful tool, but for most users it requires a conscious effort. Dictating an exam or writing on a piece of paper is more intuitive and efficient for most doctors. Computers force physicians to tear themselves away from their patients, shift their focus to a computer screen and interface with a keyboard and mouse. Doing so requires deliberate effort to navigate oftentimes-complex screens containing a myriad of dropdowns, check boxes and text boxes. The computer distracts the physician and dilutes the physician-patient encounter—unless the EMR is designed to allow physicians to practice and document exams as they have always done and are comfortable doing. That is what distinguishes the hybrid EMR from traditional EMRs.

With precision, Dr. Armstrong-Coben has identified the crux of the EMR-adoption problem.

Challenge EMR Vendors to “Put Your Money Where Your Mouth Is”

Change has arrived. The government, through the Department of Health and Human Services (HHS), will provide an incentive if you purchase and meaningfully use a “government” EMR. The problem is that the HHS incentive will only pay for the type of systems that have a dismal track record with busy, high-volume physicians.

Landmark studies have demonstrated that government EMRs, (traditional, CCHIT-style EMRs), impose financial hardship on physicians. There does not exist a single landmark study that concludes otherwise. Just ask any government EMR vendor to prove otherwise with any landmark study that meets the “smell test”:

  • The study is either large in scale or by a venerable, nationally recognized institution.
  • The study is not vendor funded.
  • The study must specifically address physician productivity. Studies that claim benefits of EMR accruing to other industry stakeholders are not relevant.

Before embarking on an expensive and risky venture into the world of government EMRs, you owe it to yourself to be 100% sure that the system is usable and adoptable for your unique practice. If you are not able to prove to CMS that you are a “meaningful user” of the EMR technology, the entire cost of an expensive EMR purchase will rest on your shoulders.

How do you make sure that your investment in a government EMR will perform just as the sales rep promises and bring your practice into the digital world, while receiving payments from the government? Easy. Insist that the vendor puts its money where its mouth is.

Before investing heavily in a government EMR, know ahead of time whether or not you will be successful. Have the vendor prove to you that they can get 2 physicians in your practice live on their system. To be fair, no money should exchange hands—only time. The two physicians and their staff will invest their valuable time learning the system and the vendor will invest its valuable time implementing and training. If, after a 30-day trial period, you are happy and can see that practice-wide implementation of the government EMR is feasible, then you sign a contract with the confidence that the investment is worthwhile. If you feel that the government EMR is not right for you, then the government EMR vendor removes the system from your office and a financial disaster is averted.

The power of this arrangement is that the government EMR vendor, whose sales rep promises the world, actually has to back up its claims with a fair trial by you, the “real-world user.” If the product does not perform as you expect, then you will not suffer the loss of a substantial investment. Go ahead and make the government EMR vendor “put its money where its mouth is.”