Enterprise EMR: One Size Does Not Fit All

In my recent post on the industry-leading EMR blog HIStalk, I discussed the impossibility of one type of EMR ever meeting the needs of all the disparate types of providers. Among the arguments I presented was that it is impossible for the same EMR product to satisfy both hospitals and private-practice physicians. Enterprise EMRs simply do not work in high-volume ambulatory settings, and it is unrealistic to expect that they would.

Apparently, this hit a nerve, given the passion and intensity of the comments, most of which addressed Epic. (You can read the comments by clicking here.) In response to Peppermint Patty’s claim that “tens of thousands of happy specialists use Epic,” Epic Mythology replied, “The idea that all specialists, or users in general, are happy with Epic is a flat-out lie. My own academic specialty clinic rebelled against Epic’s ambulatory interface as long as we could, and we switched only by force. It destroyed my clinic workflow, and I now see fewer patients while spending longer documenting. . . . I have yet to meet any doctor who really likes Epic.”

There you have it—the basic problem in our industry identified very simply by the argument between Peppermint Patty and Epic Mythology. How do we know who is right? These and several of the other comments beg the question of how a specialist—or any physician—can ferret out the truth about the potential of Epic (or any other enterprise EMR) to satisfy his or her practice’s needs? This is becoming an increasingly critical issue, given the growing pressure hospitals are putting on physicians to adopt the enterprise system by subsidizing the cost. Are physicians who succumb to this pressure getting what is right for their practices?

The following is the comment I added to HIStalk following the initial set of responses to my “Reader’s Write” post:

Judging by the comments to my post, the implementation of enterprise EMRs in ambulatory practices is a major issue confronting physicians. Most of the comments focus on Epic, the dominant player in that market. Peppermint Patty and Epic Mythology sum up the two positions—the former claims that there are many happy users of Epic, while the latter argues the exact opposite. Who is right? And how do we find out for sure? My experience speaking with thousands of physicians over the years supports Epic Mythology’s position—like him, I have not met many specialists satisfied with using enterprise EMR systems in their private practices.

Given the revived interest in EMR purchases, it’s critical for the physician community to know the truth.

Please continue the conversation by commenting on EMR Straight Talk (below) or by joining the dialogue on HIStalk.

How to Avoid the Sting of a Bad EMR Choice

The paltry adoption rate, high failure rate, and increasing number of de-installations all indicate that the process typically used to make EMR purchase decisions is seriously flawed. So how does a practice avoid making the wrong choice and buying EMR software that does not meet the needs of its physicians? I believe that they must fundamentally alter the evaluation process.

The typical process relinquishes too much power to the vendors. The practice convenes a committee that conducts a cursory review of (typically) name-brand EMRs, narrows the list down to three or four vendors, and invites the vendors to put on a “Dog and Pony Show.” Each vendor comes with a flashy presentation, shows a structured demo using a “canned” patient with a simple problem, provides several references of happy customers, and predicts a sizeable and rapid ROI. They then offer to introduce the practice to a showcase client. The problem: This process gives the physicians no way of predicting the effect on productivity, or of evaluating usability and comparative efficiency. Most importantly, physicians are left blissfully unaware of the historic failure rate of each of the EMRs they are considering.

The following are some suggestions for a more meaningful evaluation process, one that restores the power to you—the physicians and practices—and yields more realistic and valuable information:

  • Invite (i.e., require) vendors to participate in a side-by-side comparison test, which will allow you to benchmark the number of clicks it takes to accomplish the most common practice workflow tasks. Focus on the 20% of the tasks that make up 80% of a typical physician and office staff workflow—reviewing specific chart information before seeing a patient, signing off on a message, reviewing labs, or generating a prescription, for example. The other fancy features touted by EMRs are irrelevant to productivity. Clicks are time, and time is money, so this analysis will provide a true measure of relative efficiency and opportunity for increased revenue and profit generation.
  • Use real patients with typical clinical presentations, or simulated patients of your design—not the standard patient used in the vendor’s demo. This information will be directly relevant to your physicians and will demonstrate how usable and flexible each EMR is for you.
  • Ask for the names of 20 clients of your practice’s specialty and size who have recently purchased and implemented each vendor’s EMR. This will give a better idea of the vendor’s depth of experience with your type of physicians. Don’t rely on the vendor’s references—do your own networking and research. This is the only way to uncover the not-so-successful implementations in addition to the well-marketed successes.
  • When negotiating contracts, ensure that the physicians are protected on the down side—insist on having the option to be refunded the entire purchase price of the software if physicians do not adopt it. This will demonstrate the vendor‘s confidence (or lack or confidence) in their product and will ensure that you will get the highest level of implementation services and support. You must protect yourself from vendors who are anticipating a crush of orders stemming from the Stimulus Plan and who will send green employees to manage your implementation, thereby reducing your chances of success.

EMR Reform, outlined in a past blog, would dramatically facilitate this process, adding necessary transparency and restoring the balance between physicians and providers.