100% EHR Success – A Clinical Approach

Last week’s EMR Straight Talk post, “Are EHRs Being Oversold,” hit a nerve, judging by the number of readers and the volume and intensity of comments submitted by physicians. Sadly, for every one of the physicians who took the time to write, there are scores of others enduring similar experiences. The following excerpts from their comments are reflective of their frustrations:

  • We are a year into [EHR] implementation and it has been horrible and costly. What little efficiencies gained have been lost to a decrease in productivity.
  • I now require a scribe to maintain the [same] patient flow that was seen four years ago we began using the system.
  • The trouble with most EMRs is the horrible user interfaces that are designed by committees who have no concept of ease of use for ophthalmologists.
  • The programs are user unfriendly in the extreme, cumbersome and inflexible. The learning curve is seriously long and even when mastered takes a terrific amount of time away from the patient.
  • The joy-killer was encountering the endless barriers to putting my own ideas to work.
  • Training is lengthy, expensive, and markedly disruptive in an office.

Every one of these stories breaks my heart as a staunch EHR proponent—particularly since the situations could have been easily avoided.

The Root of the Problem

The problem lies in the EHR selection process. When it comes to dispensing medications, for example, no physician prescribes without knowing the success rate for that particular drug for that particular type of patient and problem being addressed. Yet, typically, physicians do not make EHR purchase decisions in the same way that they make clinical decisions—using empirical evidence and data to predict outcomes.

I’d wager that for each of the disillusioned physicians above, the EHR selection process was nearly identical:

  1. The group chose 5 to 7 vendors for consideration;
  2. Each vendor demoed their product in front of an EHR selection committee whose task was to narrow down the field to 2 or 3 finalists;
  3. The finalists performed one or more demos to a wider group of physicians and staff;
  4. The vendors each provided 2 or 3 practices as references, with specific contact names;
  5. One or two physicians and staff members spent a day visiting one reference site for each of the vendor finalists; and
  6. They selected an EHR.

Why does such an exhaustive and time-consuming selection process so often lead to failed EHR implementations?

Preventing an EHR Failure in Your Practice

To prevent an EHR failure in your practice, the flawed selection process must be altered. The first thing to understand is that the rosy experience of one or two handpicked vendor references will not guarantee a similar experience for you and your colleagues. If a vendor has sold its EHR to 100 practices and has as few as 5 successful implementations, you will be referred to one of these 5 practices. A visit to 1 or 2 of these 5 successful practices may leave you with a warm and fuzzy feeling and the expectation that, because they were successful, your success is virtually assured. In this case, however, your real probability of success would only be 5%.

Separating the Wheat from the Chaff

So how do you quickly eliminate vendors with lackluster success records before you and your staff waste hours watching slick sales demonstrations of sexy software with “must-have” features? Separating the wheat from the chaff is simple—just ask all your initial set of EHR vendors for lots of references. If a vendor cannot produce at least 2 references for each year they have been in business, run the other way. Do not accept any excuses for being unable to provide you with the number of references that you seek. (A common excuse is that the vendor wishes to protect the privacy of its clients.) If they had lots of references, they would give them to you in a heartbeat—happy customers are always willing to show their successes to others.

Many of the initial vendors chosen will not be able to produce a satisfactory number of references. This should narrow down the number left for you to consider, and it will save a tremendous amount of valuable physician and staff time.

Statistically Significant Reference Checking

At this point, your list of vendors will likely include just the one or two that have provided you with a meaningful reference list. You may have to accept the bias created by the fact that the references are carefully handpicked by the vendor(s), but it is imperative that you do not limit your inquiries to the specific physicians identified by the vendor. Typically, these are the practice administrator and one or two physicians who had spearheaded the EHR purchase for the practice; as a matter of pride, they are more likely to paint a rosy picture of the EHR than to acknowledge its shortcomings. The only way to avoid this trap is to speak with other physicians at the reference practices. This is easy to do. When you get the reference list from an EHR vendor, ask them to include the practice websites, then randomly choose physicians to call from the physicians’ bio pages. These physician-to-physician calls should be short (only 10 minutes each) and you should ask specific questions about cost, efficiency, and number of patients seen.

  1. When did you install your EMR?
  2. How long was the installation/implementation process?
  3. How would you describe the installation/implementation process?
  4. Was the system as user friendly as the demonstration by the salesperson?
  5. How many patients per hour/per day did you (and your partners) see before the installation/implementation of your EMR?
  6. How many did you see after?
  7. Approximately how much more time do you devote to entering exam data into your EMR now compared to how you documented exams before you began using an EMR?
  8. How do you like the quality of the EMR-generated exam notes?
  9. Have you had to hire scribes to enter data for you? If so, how many and what is their annual cost?
  10. Has your EMR completely eliminated the paper charts in your practice?
  11. Given your practice’s experience with your EMR, would you recommend it to a similar practice?

How much of your time should this type of random reference checking take? Not much! Ten 10-minute calls (less than 2 hours of time) to randomly chosen physicians will yield more valuable data on your chances of success than having a slew of vendors demo their products to your doctors and staff for hours on end. Only after having conducted the due diligence described above will you be able to derive real value from spending your time seeing demos—because you will only be seeing demos of the one or two EHRs that you now know are likely to deliver success.

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.