EMR Purchase: Caveat Emptor

Physicians practice evidence-based medicine. They base clinical decisions on evidence gained from scientific research and experience. As patients, this is the source of our confidence in their diagnoses and treatment plans for us. Unfortunately, an alarming number of physicians do not apply evidence-based decision-making to their EMR purchases. This explains the 50–80% EMR failure rate documented in the Milbank Quarterly and cited by the AMA.

Recently, I’ve spoken with several ophthalmology practices that are struggling under the weight of unsuccessful EMR implementations—many of these situations would have been averted by asking the right people the right questions at the right time—before signing the EMR contract. Let me share a few examples of how aggressive due diligence uncovers important facts:

Buyer BewareAn ophthalmology practice purchased an EMR from [Vendor 1] based on its ad stating that nearly 500 ophthalmology practices use a [Vendor 1] product. Had the physicians asked for the names of 10 ophthalmology practices of their size that use this vendor’s EMR, they would have learned—by the lack of response—that most of the 500 practices use the vendor’s practice-management system, not its EMR. Don’t fall prey to deceptive marketing.

Beware of references with vested interests. For example, a physician would never know that the reference for [Vendor 2] has an ownership interest in the vendor’s company. Not surprisingly, the reference physician described the EMR as “excellent.” It was only a subsequent blog comment from another physician in the practice that revealed that, after 3 years, she still schedules 6 fewer patients each day and has hired a skilled technician to assist her, adding $37,500 per year in costs.

Another practice made a visit to [Vendor 3’s] reference site and learned that the physicians in the practice are, in fact, using the EMR. If they had probed further and asked about staffing, however, they would have learned that instead of 8 scribes, this practice now employs 24 scribes to handle the necessary data entry—two for each ophthalmologist (instead of one before the EMR adoption), and one for each optometrist (when the optometrists had never needed any scribes at all before the EMR).

It’s equally important to randomly select physicians to call. Do not limit your conversations to those physicians hand-picked by the vendor—other physicians in the practice will always take calls from colleagues. Ask each physician how many patients he or she sees each day now as opposed to before EMR implementation. Within the same practice that purchased [Vendor 4’s] EMR, physicians using the EMR successfully are those who see only 25 patients per day, while the ones who see 60 patients daily do not use it because of its effect on their productivity.

If you apply the same due diligence and evidence-based decision-making to your EMR search that you do to treating your patients, you will have the information you need to ensure that the EMR you select will be the right EMR for your practice.

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.