Most EHRs Disappoint Specialists

The vast majority of EHRs are outright failing the specialists. Is this news? Surely not to those physicians suffering EHR implementation disasters, but thanks to KLAS, we now have hard data to confirm the anecdotal evidence. It is provided in the recent KLAS report, and eloquently described by Ken Terry in his recent article in Information Week. His title, however, “EHR’s Aren’t Specialist-Friendly Enough,” underestimates the seriousness of the problem. And the problem will only get worse as more specialists rush to purchase EHRs under the pressure of impending meaningful use deadlines.

In an industry where the EHR satisfaction scores by specialty range from a paltry high of only 7.6 (on a scale of 10) for internal medicine and family practice to an embarrassing low of 5.8 for oncologists and ophthalmologists, most specialists rate their EHRs in the barely passing range between 6.2 and 6.8.


Source: KLAS as reprinted in HIStalk

Let’s look at these scores as grades—the best EHRs are only earning a C (76%); orthopedists are trying to make a go of EHRs that are squeaking by with a D (65%); and some specialists are saddled with EHRs that are simply flunking out (58%).

And these scores are averages. Assuming a normal distribution of responses (see example of bell curve for ophthalmology, below), there are many physicians who rate their EHRs considerably lower than the average—giving scores of 48%, 38%, or even lower. (Readers who are physicians know what happens to students who get a 38% on an organic chemistry final exam: dreams of medical school quickly disappear as these students are weeded out of the candidate pool!)

Of course, just as there are some specialists who rate their EHRs below the average, there are also some who score theirs at the high end of the bell curve (in the orange section). Oh, and guess where a vendor is going to take a prospective customer for a site visit?

So, what’s a specialist to do to increase the chance of EHR success? Play it safe and go with a name brand, generic EHR? Clearly not! That strategy is anything but safe. The legacy EHRs are all built to support the needs of primary-care physicians—it is no surprise that internists and family practitioners are less dissatisfied with their EHRs than their specialist colleagues are.

Here are some tips:

  • Start with the KLAS report, “Ambulatory EMR by Specialty Study 2012: Finding the Fit”, and identify those EHRs that have high ratings in your specialty.
  • Make sure that these vendors have a large network of providers in your specialty.
  • Perform comprehensive due diligence, calling physicians that you select.
  • Beware of vendor-selected site visits—these physicians should not be expected to be representative of the majority experience.

You can’t cheat when it comes to selecting an EHR. After all, it may be the EHR that gets the bad grade, but it’s you who is going to have to pay.

EHR Usability – Let Physicians Decide

Usability has become the focus of a great deal of attention in the EHR world. The HIT Policy Committee has talked about making usability a component of meaningful use—recognizing that spending $36 billion to incentivize and support physicians to adopt EHRs means that we can no longer close our eyes to the historically high rate of EHR failures. Fears about lack of usability, and the resulting impact on productivity, have contributed to physicians’ reluctance to move forward with implementation, and EHR incentives will not sustain adoption beyond the first payments if physicians find their EHRs unusable.

To address these issues, the Committee held a day-long hearing on usability, and on June 7, NIST (National Institute for Standards and Testing) convened a workshop to discuss the state of EHR usability. Significant work is being done by NIST, as well as by academic institutions, research and trade groups, and vendors, to determine how to measure, evaluate, and improve the usability of EHRs.

I hope that those involved in the efforts to advance EHR usability will consider the following points:

  • The only people who can truly define usability are the users—i.e., physicians and other providers. Usability relates to the comfort, ergonomics, and acceptability of a particular application interface to its users. As such, it is the experiences and feedback provided by those users that must be the driving force behind any shift toward greater usability.
  • Usability can be measured, but not legislated. Because personal subjectivity will always be an important factor in each individual user’s judgment about what is ergonomic, comfortable, and generally acceptable, there will always be room for a variety of approaches. Attempts to legislate the best way will inevitably accommodate only a narrow range of users, leaving those with varying preferences and workflows without software to satisfy their usability requirements.
  • Usability must be evaluated not only from the perspective of primary care physicians, but also that of specialists. Specialists provide different types of care and have very different expectations of their EHRs. Treating specialists as an afterthought—as happened in the initial formulation of the meaningful use requirements—would be a major disservice and undermine the serious work being done to define usability.

There is a great opportunity here for the government to provide advice and education regarding EHR usability—this could go a long way to furthering successful EHR adoption. It would be a major mistake, however, for the government’s role to extend to legislating or mandating usability standards. That would sap innovation, push creative vendors out of the market, and turn EHR adoption back to where it was before the meaningful use incentives.

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.