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.

Which Is Best: Client-Server EMR or Web-Based EMR?

Three things initially attract people to web-based EMRs over client-server EMRs: they are easier to deploy and upgrade, demand less IT support, and require less hardware. While it is true that web-based deployment and upgrades are easier, client-server technology actually delivers far superior benefits and long-term cost savings on the second two criteria.

For a start, the IT support argument ignores the significant trade-off between physicians’ time and IT staff time. Physician productivity is a crucial part of any practice’s bottom line, which amplifies the limitations imposed by EMRs whose architecture relies on the Internet. Anyone who’s compared the speed and performance of PC-installed Outlook with Outlook’s Web mail accessed through Internet Explorer knows that client-server software affords a richer, crisper user interface that outperforms browser- or web-based software in terms of the number of clicks and the ease of use. Gaining just 30 seconds of productivity per exam with a fast and robust client-server solution can generate an additional $50,000 per year or more for high-volume specialists.

Internet lag/latency can also be very costly, particularly during the “Internet Rush Hour” when millions of teenagers come home from school to play online games, view YouTube videos, and communicate with each other on Facebook. This may result, over the course of a typical patient exam, in repeated several-second delays between the physician’s web-based EMR and the server where the patient’s data exists, increasing the time it takes to pull up patient information, make a prescription, retrieve a document, or display an image. These protracted, productivity-sapping delays can have a significant impact on revenue.

When it comes to hardware, web-based vendors tout their cost savings by claiming that all you need is a computer with an Internet connection to be up and running. This is not quite true—like all client-server offerings, a web-based EMR requires exam-room PCs, tablets, and laptops, as well as computers at the nursing stations, a wireless networking infrastructure, and a Windows server to manage logins and network security. In fact, the only difference in hardware between the two solutions is that the client-server solution needs an in-house, plain-vanilla Microsoft Windows server, which costs just a few hundred dollars per year per physician when amortized over the life of the server. In contrast, practices using web-based EMRs must absorb the frequently exorbitant fees that are built into the subscription model to cover the cost of the web-based company’s sophisticated data center. Over the long term, a client-server offering often costs far less than a web-based subscription offering, and a well-designed client-server EMR always delivers productivity-enhancing benefits that save physicians both time and money—something they sorely need in an era of lower reimbursements and higher patient volumes.

EMR References: Cast a Wider Net

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.

Impact of EMR on Physician Productivity

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.

EMR Adoption: Why Are You Still on the Fence?

A growing number of physicians—particularly specialists—are no longer on the fence when it comes to the government’s EHR incentives. As evidenced by a recent spate of articles and blogs—one of the more compelling ones being “Is HITECH Working?: Key Physicians Will Sit on the Sidelines (At Least for Now)”—they realize that the costs outweigh the benefits. Physicians have decided that they:

  • 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!

Government EHR Incentives: Are You Out of Luck—or Lucky?

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.

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.