Client references and site visits can be a rich source of valuable information when you’re shopping for an EMR—but only if approached critically and after conducting your own due diligence. The graph below illustrates the limitations of relying on vendor-supplied client references to make an informed EMR purchase decision.
This graph represents the effect of EMR adoption on physician productivity, given the acknowledged 50–80% failure rate of traditional EMRs—specialists being on the higher end of the range. Immediately upon adoption, physicians experience a significant reduction in the number of patients they can see, and over time, they hope to regain their productivity. Some are able to achieve their pre-EMR levels, and a small number see an increase above that level—the latter are the physicians in the orange-shaded section. These are the physicians whom vendors will identify as references and whose practices will be offered for site visits.
Every vendor will have a few good references and can take potential customers to visit a “show site” client, but this is not necessarily representative of the experience of the majority of users—the experience that you can likely expect.
If this graph instead portrayed the results of a clinical trial for a new drug, would a physician prescribe this medication based on the fact that 100 (of the 1,000) patients in the study showed positive effects? Clearly not!
Ask the vendor for—and insist on—at least 10 to 15 references of practices in your specialty and at least a few that are close in size to yours. If a vendor cannot provide this, there is reason to question whether its EMR is right for your practice. Call a physician of your choosing in the reference practice(s)—selecting at random from the group’s website is most likely to yield an objective evaluation. Don’t be fooled by one reference, one hand-picked physician, or one “show site” visit.
Will not buy the type of EMR that is difficult to use and has not worked for other physicians in their specialty;
Will not risk the costs of a failed implementation;
Cannot tolerate the decrease in productivity—seeing fewer patients and generating less revenue;
Have established as a priority improving the quality of patient care they deliver, rather than collecting and reporting data that the government wants;
Cannot afford to take on unnecessary additional administrative burdens in the face of declining reimbursements;
Are not worried about potential penalties that will be relatively small, if they are even imposed at all; and
Are not interested in the government’s program, the benefits of which accrue primarily to other stakeholders, and not to their practice.
So why are these physicians, who have determined that government incentives are not relevant or achievable, still on the fence about adopting an EMR solution that will deliver measurable benefits? Staying with paper charts is not a good business strategy because there is nothing more inefficient!
The costs associated with the excess staff needed to manage these medical records are massive and wasteful—these positions can be eliminated or the employees can be more effectively used in revenue-generating or patient-care roles.
Paper charts hinder practice growth because adding physicians requires a proportional increase in support staff—medical records, billing, nurses, and medical assistants—and because physicians can’t see more patients without lengthening their work hours.
Slow responsiveness to primary care physicians limits referral volume.
Profitability is further affected by billing bottlenecks that delay revenue collection.
The chaos associated with trying to manage paper charts has a damaging effect on staff morale and creates rampant frustration among patients, physicians, and staff.
Paper charts are a malpractice nightmare—prescriptions are not consistently documented, orders are not easily tracked, and medical decisions are often made without complete clinical information.
You cannot afford to maintain the status quo.
Physicians can transform their practices without the government—there are excellent EMR solutions available, such as the hybrid EMR. It’s time to become digital. It’s time to get off the fence!
A reader raised an interesting question on the EMR and HIPAA blog this week. She asked if practices without a Medicare or Medicaid patient base are simply “out of luck” with regard to the government’s EHR incentive program. John Lynn responded:
“…not qualifying for the EMR stimulus money might just be the best thing that’s happened to your practice. That means you won’t be distracted and you don’t need to wait. You can hone in on the other EMR benefits and start reaping those benefits without all the bureaucracy.”
In other words, she can feel free from government pressure to make any particular type of EMR decision. This is exactly the same advice I give to all physicians, regardless of their eligibility for the government’s program—the voluntary nature of the EHR incentives gives you absolute freedom to make the decision that is in the best interests of your practice. Sandra Brown, M.D., reflected that feeling—shared by many physicians—in her response to a past EMR Straight Talk post, when she said that she felt “liberated” by the fact that the government couldn’t force physicians to take the money.
Physicians should use this freedom to evaluate EMRs based on ease of use, speed, flexibility, and any other criteria that they—rather than the government—feel will facilitate delivery of the anticipated benefits, such as:
A practice-wide, 100% successful adoption rate
Increased physician productivity
More efficient use of staff time
Revenue growth with decreased overhead
Enhanced patient care and service
Back-office efficiencies—improved revenue cycle
Decreased malpractice exposure
These benefits are guaranteed to far exceed an elusive $44,000 incentive, and physicians can begin realizing a significant ROI immediately—if they chose the right EMR.
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.
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.
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.
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.