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.

The Elephant in the Room

The search for the perfect EMR involves an extensive list of criteria related to features and functions, cost, hardware requirements, certification, references—and since February, the potential to obtain government incentive money. Search committees are assembled, consultants are engaged, RFPs are solicited, presentations are made, and references are checked. But there is a big elephant in the room that everyone is ignoring—physician productivity.

The effects of productivity are enormous. Changes in physician productivity dramatically and directly impact the practice’s bottom line. You can calculate the cost for yourself using the Productivity Calculator discussed in a prior blog. Physician productivity has broader societal impacts as well. Decreased productivity means fewer patients seen in the face of higher demand for care by aging baby boomers and the massive numbers of newly insured patients under proposed health care reform legislation. This is further compounded by the shortage of physicians.

Why is no one looking at productivity? Why aren’t physicians and medical societies insisting that productivity information be made available and be the focus of the EMR selection process? Why do RFPs—typically written by consultants—contain no questions about productivity? CCHIT certification has never included any evaluation of productivity, and neither does the government’s “meaningful use” matrix. Even at the recent MGMA Annual Conference there was no mention of productivity in a session on implementing EHR technology. A reasonable explanation might be that objective information about comparative productivity is not available. However, this problem could be remedied by EMR Reform—but that proposal is meeting with resistance within the industry.

Some of the answers to the questions above are less surprising than others. I believe that vendors are afraid of what comparative benchmarking would reveal about their products’ performance under close scrutiny of productivity. It is not in the vendors’ interest to yield control of the EMR evaluation process—not when scripted presentations permit skirting the productivity issue entirely. Consultants don’t feel confident that they have the tools to effectively compare productivity, particularly if vendors are not supportive of productivity measurement. What confounds me, however, is the lack of concern being expressed by physicians and their representative professional groups. I can only assume that it is due to the fear-based marketing efforts to which they are being subjected. Physicians are being told that they must buy an EMR because the government requires it and because everyone else will buy one—neither of which is true. What physicians should be fearful of is the loss of productivity that they will suffer if they do not consider productivity as a primary factor in the EMR selection process.

At next week’s HIT Policy Committee meeting, defining “meaningful use” for specialists will be a primary agenda item. We will advocate that meeting the government’s goals for widespread EHR adoption requires that physician productivity—the elephant in the room—be addressed.

Planning for the Flood

I spent the last few days attending the annual conference of the Medical Group Management Association (MGMA) in Denver, where there was a lot of talk about the financial challenges practices are facing and about the government’s EHR incentives.

Robert Tennant, MGMA’s Senior Policy Advisor, acknowledged that few groups will be eligible for the incentives when the government’s program begins in 2011. According to William Jessee, M.D., President and CEO, the vast majority of practices do not currently have any type of EHR, and despite being pressured by vendors that the time to purchase and implement one is now, physicians are reluctant to commit the resources necessary to do so. He attributed this to the financial effects of the recession—an unprecedented negative growth in practice revenue that is resulting in decisions to postpone capital investments. Add to this the pervasive confusion surrounding the incentives themselves, and the forecast is for wholesale inaction.

All of this has reinforced my belief that it is more important than ever for physicians to make good business decisions, and to do everything they can to enhance—or at a minimum, preserve—productivity. Not only will practices be faced with the financial pressures and declining reimbursements cited by the MGMA, but additional factors will make productivity critical. The impending flood of aging baby-boomers and the newly insured (through healthcare reform legislation)—coupled with a growing physician shortage—will swamp the healthcare system. This increased demand for care creates an opportunity, but only physicians who can leverage EHR technology to boost their productivity will really keep their heads above water.

An Open Letter to HHS Secretary Sebelius

We are very encouraged that the Voice of the Physician Petition has been acknowledged at the highest levels of government. After HHS (Department of Health and Human Services) Secretary Kathleen Sebelius received the petition that SRS sent to her—and simultaneously hand delivered to the HIT Policy Committee—Secretary Sebelius asked Dr. Blumenthal to respond to me. As head of the Office of the National Coordinator for Health Information Technology, Dr. Blumenthal chairs the HIT Policy Committee and, together with Secretary Sebelius, will accept or modify the recommendations on “meaningful use” and EHR certification that come from that committee and from CMS (Centers for Medicare & Medicaid Services). In the interest of continuing this conversation, I am extending the following invitation to Secretary Sebelius, as I already have to Dr. Blumenthal:

Dear Secretary Sebelius:

I received Dr. Blumenthal’s letter and was glad to hear that you appreciate the input provided in the Voice of the Physician Petition. The ability of the EHR incentives to successfully encourage widespread adoption of EHRs is inextricably linked to the belief by physicians that EHR technology is of benefit to them, as well as to all the other stakeholders in the healthcare delivery system.

I would like to arrange a brief meeting with you to discuss these very important issues in person. As the CEO of SRS, with 12 years of experience listening to and working with front-line physicians, I can offer you some valuable insights into what community-based physicians are looking for and how they perceive the legislation—likely a different perspective than that being presented by committee members.

SRSsoft was recently named to the Inc. 5000 list of most rapidly growing companies, and was identified as one of the top 100 healthcare companies. Our success and growth is directly attributable to the fact that our EMR development is driven entirely by the needs of private-practice physicians.

As the representative of thousands of physicians who want their voices heard—SRS clients and non-clients alike—I would be happy to come to Washington to talk with you. I am confident that you would find the conversation valuable.

Here’s Proof: Your Time is Worth More Than You Think

When I speak with physicians and share with them this calculator, they are astonished to see the true value of their time.

Physician productivity is a major driver of practice revenue and profitability. Today’s rising practice costs, a more challenging reimbursement environment, the looming payment reform, a physician shortage, and the aging baby-boomer population make productivity increasingly critical. Whether you are comparing an EMR to paper charts, one traditional EMR to another, or a point-and-click EMR to a hybrid EMR, seconds count.

Last week, I suggested benchmarking to compare the relative effects on productivity of the different EMRs a practice might be considering. My EMR Reform plan includes “click” comparisons as a “report card” measure of efficiency. It may sound trivial—a few clicks more or less, or a few seconds here and there, couldn’t have much of an impact. But they do.

Consider this: approximately 80% of clinical workflow consists of the repetitive performance by physicians and medical assistants of 20% of their tasks. If generating a prescription requires 8 clicks in one EMR and 3 clicks in another, and each click takes just one second of a physician’s time, every prescription written has a potential impact—positive or negative—of 5 seconds on physician productivity. Add in the differential for other common workflows such as reviewing chart notes, sending a message, or reviewing and signing a test result (number of clicks, number of screens that must be navigated, etc.), and it is reasonable to assume that you can increase—or decrease—productivity by 30 seconds per exam, depending on the technology you choose.

For a typical orthopaedic surgeon who generates $1.1 million in revenue by seeing 125 patients per week, conducting office hours 20 hours per week, and taking 5 weeks of vacation, this 30-second-per-exam increase in productivity would enable this physician to generate an additional $57,000 per year (or $285,000 over 5 years). Conversely, an EMR that decreases productivity by 30 seconds per exam would cost this physician $285,000 over 5 years. Because this represents marginal revenue, it goes straight to the bottom line as almost entirely profit (or loss).

How to Avoid the Sting of a Bad EMR Choice

The paltry adoption rate, high failure rate, and increasing number of de-installations all indicate that the process typically used to make EMR purchase decisions is seriously flawed. So how does a practice avoid making the wrong choice and buying EMR software that does not meet the needs of its physicians? I believe that they must fundamentally alter the evaluation process.

The typical process relinquishes too much power to the vendors. The practice convenes a committee that conducts a cursory review of (typically) name-brand EMRs, narrows the list down to three or four vendors, and invites the vendors to put on a “Dog and Pony Show.” Each vendor comes with a flashy presentation, shows a structured demo using a “canned” patient with a simple problem, provides several references of happy customers, and predicts a sizeable and rapid ROI. They then offer to introduce the practice to a showcase client. The problem: This process gives the physicians no way of predicting the effect on productivity, or of evaluating usability and comparative efficiency. Most importantly, physicians are left blissfully unaware of the historic failure rate of each of the EMRs they are considering.

The following are some suggestions for a more meaningful evaluation process, one that restores the power to you—the physicians and practices—and yields more realistic and valuable information:

  • Invite (i.e., require) vendors to participate in a side-by-side comparison test, which will allow you to benchmark the number of clicks it takes to accomplish the most common practice workflow tasks. Focus on the 20% of the tasks that make up 80% of a typical physician and office staff workflow—reviewing specific chart information before seeing a patient, signing off on a message, reviewing labs, or generating a prescription, for example. The other fancy features touted by EMRs are irrelevant to productivity. Clicks are time, and time is money, so this analysis will provide a true measure of relative efficiency and opportunity for increased revenue and profit generation.
  • Use real patients with typical clinical presentations, or simulated patients of your design—not the standard patient used in the vendor’s demo. This information will be directly relevant to your physicians and will demonstrate how usable and flexible each EMR is for you.
  • Ask for the names of 20 clients of your practice’s specialty and size who have recently purchased and implemented each vendor’s EMR. This will give a better idea of the vendor’s depth of experience with your type of physicians. Don’t rely on the vendor’s references—do your own networking and research. This is the only way to uncover the not-so-successful implementations in addition to the well-marketed successes.
  • When negotiating contracts, ensure that the physicians are protected on the down side—insist on having the option to be refunded the entire purchase price of the software if physicians do not adopt it. This will demonstrate the vendor‘s confidence (or lack or confidence) in their product and will ensure that you will get the highest level of implementation services and support. You must protect yourself from vendors who are anticipating a crush of orders stemming from the Stimulus Plan and who will send green employees to manage your implementation, thereby reducing your chances of success.

EMR Reform, outlined in a past blog, would dramatically facilitate this process, adding necessary transparency and restoring the balance between physicians and providers.

Lost Opportunity: EMR Reform Was within Our Grasp

In October of 2007, the government (or specifically, CMS—the Centers for Medicare and Medicaid Services) had a great idea: It announced a 5-year EHR demonstration project. The project had goals similar to the EMR Reform concept detailed in last week’s EMR Straight Talk. The government set about to scientifically investigate whether “investing time and money to convert . . . to EHR is worthwhile [for physicians] or not.” The project would also specifically measure physician satisfaction, exploring how EHRs affect workflow and identifying which functions physicians actually use. The goal was to “examine practices’ experience in implementing and using EHRs” and to evaluate “providers’ perceptions of the effects on their practice and patients.” This was a great start at a sorely needed objective evaluation of the efficacy of EMR in physician offices.

Why did the government fund this program to the tune of $150 million? My guess is that it was because they recognized that no study existed to support the commonly held—but undocumented—assumptions regarding the value of EMRs to physicians. The few landmark studies that have been conducted have focused on the value to other stakeholders—insurance companies, the government, etc.—but not to physicians.

The demonstration project had a start date of June 1, 2009, and will encompass 5 years of data collection. Yet on February 17, 2009, in a rush to push through legislation, and encouraged by special interest groups, President Obama signed the Stimulus Bill before the first demonstration test site was even operational. The government will now spend $36 billion supporting the very same EHRs they had wanted to study, but without the benefit of the potentially valuable information that the demonstration project could have provided. Nor will they have heard from physicians about what actually works in the real world of medical practice.

So here we are, embarking on a massive government program enticing physicians to invest in and implement software that the government itself has acknowledged is unproven in value—and urging physicians strongly that the time to do so is now—despite the fact that the demonstration project’s Phase I is just beginning and preliminary results will not be available until 2014.

Don’t we have a responsibility to provide physicians with at least the level of decision support to which they have access when they buy a car? Regrettably, this failure represents a lost opportunity to produce an EMR report card that would let physicians see what is really going on “under the hood”—before we expect them to invest their hard-earned money. Never before has the argument for EMR Reform been so compelling.