The Elephant in the Room

The search for the perfect EMR involves an extensive list of criteria related to features and functions, cost, hardware requirements, certification, references—and since February, the potential to obtain government incentive money. Search committees are assembled, consultants are engaged, RFPs are solicited, presentations are made, and references are checked. But there is a big elephant in the room that everyone is ignoring—physician productivity.

The effects of productivity are enormous. Changes in physician productivity dramatically and directly impact the practice’s bottom line. You can calculate the cost for yourself using the Productivity Calculator discussed in a prior blog. Physician productivity has broader societal impacts as well. Decreased productivity means fewer patients seen in the face of higher demand for care by aging baby boomers and the massive numbers of newly insured patients under proposed health care reform legislation. This is further compounded by the shortage of physicians.

Why is no one looking at productivity? Why aren’t physicians and medical societies insisting that productivity information be made available and be the focus of the EMR selection process? Why do RFPs—typically written by consultants—contain no questions about productivity? CCHIT certification has never included any evaluation of productivity, and neither does the government’s “meaningful use” matrix. Even at the recent MGMA Annual Conference there was no mention of productivity in a session on implementing EHR technology. A reasonable explanation might be that objective information about comparative productivity is not available. However, this problem could be remedied by EMR Reform—but that proposal is meeting with resistance within the industry.

Some of the answers to the questions above are less surprising than others. I believe that vendors are afraid of what comparative benchmarking would reveal about their products’ performance under close scrutiny of productivity. It is not in the vendors’ interest to yield control of the EMR evaluation process—not when scripted presentations permit skirting the productivity issue entirely. Consultants don’t feel confident that they have the tools to effectively compare productivity, particularly if vendors are not supportive of productivity measurement. What confounds me, however, is the lack of concern being expressed by physicians and their representative professional groups. I can only assume that it is due to the fear-based marketing efforts to which they are being subjected. Physicians are being told that they must buy an EMR because the government requires it and because everyone else will buy one—neither of which is true. What physicians should be fearful of is the loss of productivity that they will suffer if they do not consider productivity as a primary factor in the EMR selection process.

At next week’s HIT Policy Committee meeting, defining “meaningful use” for specialists will be a primary agenda item. We will advocate that meeting the government’s goals for widespread EHR adoption requires that physician productivity—the elephant in the room—be addressed.

Here’s Proof: Your Time is Worth More Than You Think

When I speak with physicians and share with them this calculator, they are astonished to see the true value of their time.

Physician productivity is a major driver of practice revenue and profitability. Today’s rising practice costs, a more challenging reimbursement environment, the looming payment reform, a physician shortage, and the aging baby-boomer population make productivity increasingly critical. Whether you are comparing an EMR to paper charts, one traditional EMR to another, or a point-and-click EMR to a hybrid EMR, seconds count.

Last week, I suggested benchmarking to compare the relative effects on productivity of the different EMRs a practice might be considering. My EMR Reform plan includes “click” comparisons as a “report card” measure of efficiency. It may sound trivial—a few clicks more or less, or a few seconds here and there, couldn’t have much of an impact. But they do.

Consider this: approximately 80% of clinical workflow consists of the repetitive performance by physicians and medical assistants of 20% of their tasks. If generating a prescription requires 8 clicks in one EMR and 3 clicks in another, and each click takes just one second of a physician’s time, every prescription written has a potential impact—positive or negative—of 5 seconds on physician productivity. Add in the differential for other common workflows such as reviewing chart notes, sending a message, or reviewing and signing a test result (number of clicks, number of screens that must be navigated, etc.), and it is reasonable to assume that you can increase—or decrease—productivity by 30 seconds per exam, depending on the technology you choose.

For a typical orthopaedic surgeon who generates $1.1 million in revenue by seeing 125 patients per week, conducting office hours 20 hours per week, and taking 5 weeks of vacation, this 30-second-per-exam increase in productivity would enable this physician to generate an additional $57,000 per year (or $285,000 over 5 years). Conversely, an EMR that decreases productivity by 30 seconds per exam would cost this physician $285,000 over 5 years. Because this represents marginal revenue, it goes straight to the bottom line as almost entirely profit (or loss).

Lost Opportunity: EMR Reform Was within Our Grasp

In October of 2007, the government (or specifically, CMS—the Centers for Medicare and Medicaid Services) had a great idea: It announced a 5-year EHR demonstration project. The project had goals similar to the EMR Reform concept detailed in last week’s EMR Straight Talk. The government set about to scientifically investigate whether “investing time and money to convert . . . to EHR is worthwhile [for physicians] or not.” The project would also specifically measure physician satisfaction, exploring how EHRs affect workflow and identifying which functions physicians actually use. The goal was to “examine practices’ experience in implementing and using EHRs” and to evaluate “providers’ perceptions of the effects on their practice and patients.” This was a great start at a sorely needed objective evaluation of the efficacy of EMR in physician offices.

Why did the government fund this program to the tune of $150 million? My guess is that it was because they recognized that no study existed to support the commonly held—but undocumented—assumptions regarding the value of EMRs to physicians. The few landmark studies that have been conducted have focused on the value to other stakeholders—insurance companies, the government, etc.—but not to physicians.

The demonstration project had a start date of June 1, 2009, and will encompass 5 years of data collection. Yet on February 17, 2009, in a rush to push through legislation, and encouraged by special interest groups, President Obama signed the Stimulus Bill before the first demonstration test site was even operational. The government will now spend $36 billion supporting the very same EHRs they had wanted to study, but without the benefit of the potentially valuable information that the demonstration project could have provided. Nor will they have heard from physicians about what actually works in the real world of medical practice.

So here we are, embarking on a massive government program enticing physicians to invest in and implement software that the government itself has acknowledged is unproven in value—and urging physicians strongly that the time to do so is now—despite the fact that the demonstration project’s Phase I is just beginning and preliminary results will not be available until 2014.

Don’t we have a responsibility to provide physicians with at least the level of decision support to which they have access when they buy a car? Regrettably, this failure represents a lost opportunity to produce an EMR report card that would let physicians see what is really going on “under the hood”—before we expect them to invest their hard-earned money. Never before has the argument for EMR Reform been so compelling.

EMR Reform: A Plan to Spur Adoption

A free market is the most powerful economic force on earth. According to Adam Smith’s The Wealth of Nations, this is because free markets let people make informed purchase decisions based on how products further their own interests. If left to operate without interference, a truly free market rewards products that consumers deem superior, and puts companies with inferior products out of business.

However, informed purchase decisions can be made only when unbiased information is available. Currently, in the EMR market, such information about the myriad of product offerings is largely absent, and purchasers must rely on unauthenticated vendor claims. It’s no wonder that physicians are reluctant to purchase these expensive systems—the risk of a financial disaster looms over their heads.

The barriers to EMR adoption are not problems that government incentives can even begin to remedy. What is needed to truly drive adoption is major healthcare IT reform. Transparency and full disclosure must be introduced in order for market forces to work and for widespread adoption to occur. Just imagine the effect of the following EMR reform proposal:

1. Increase the EMR success rate (and reduce the lamentable failure rate) by increasing product quality and usability through competitive benchmarking.

Physicians should have access to “click” comparisons that measure the efficiency of each EMR in conducting common office workflows—finding a chart, reviewing chart information, sending a message, creating a problem list, creating a prescription, signing off on a lab, or ordering a test. These comparisons would create a race to efficiency as vendors are forced to think about physicians’ workflow and productivity, and would ultimately create more usable, superior products. After all, which vendor would want to be known as the most point-and-click-heavy vendor in the marketplace?

2. Provide transparency by issuing audited vendor report cards.

A report card would measure each vendor’s previous three years of sales and their success/de-install rate by specialty. In the auto industry, the information available through crash-test results and the J.D. Power and Associates consumer-satisfaction reports give manufacturers the motivation to build cars that meet consumers’ needs and preferences. EMR purchasers should have similar quality data enabling them to make successful choices as well. KLAS has laid the important groundwork with their customer-survey-based comparative EMR data, but additional data from objective tests and non-vendor-selected customers would round out the picture.

3. Take the systemic risk out of purchasing an EMR by allowing providers to return EMR licenses if they do not perform as promised—in other words, an EMR Lemon Law.

A return policy would profoundly and positively impact adoption rates since physicians would be less likely to fear being victimized by false sales pitches, and vendors would be more likely to ensure that implementations went smoothly. It would also ensure that products not appropriate for a particular specialty would not be sold to those physicians.

These simple healthcare IT reforms will level the playing field and restore the sorely needed balance between vendors and physicians. The result will be faster, more confident purchase decisions and increased long-term adoption.