EMR Straight Talk Centennial Blog—It’s Still About Productivity

This is my 100th EMR Straight Talk post, and a lot has changed in the EHR world since the blog’s inception—but some things have not. Productivity is still the name of the game in EHRs, especially for specialists.

There is no question that the government incentives have stimulated interest in EHR adoption, but according to a recent physician survey, that is not the primary reason that providers are looking to implement one. “Quality and efficiency” ranked higher than the EHR incentives as the goal of EHR implementation, according to this report by CapSite—a healthcare technology research company. Heightened interest in efficiency is not surprising, given that in another study (by MGMA), physicians identify rising operating costs as a tremendous challenge.

Although the above data was not cut by specialty, I know from my experience in the field that these issues are magnified in specialty practices. MGMA found that of all physicians, orthopaedists face the greatest challenge in successfully implementing EHR systems. Ophthalmologists have such distinct needs that the American Academy of Ophthalmology took the time to publish an article defining the specific characteristics that an ophthalmology EHR must have to be valuable in their members’ practices.

When you read through the list of requirements, they all tie into the impact on productivity and efficiency—factors critical to both of these specialties given their particularly high patient volumes. The implications for EHR selection are significant, and have not changed since I wrote my first EMR Straight Talk post.

Thank you for reading and commenting!

EHRs and Productivity Loss: How Can This Be Acceptable?

The purpose of automation is to increase efficiency and productivity. Every industry that has undergone the transformation from paper to digital has realized these benefits immediately . . . every industry, that is, except the EHR industry. Why is this acceptable?

Even the AMA acknowledges this failure—and yet seems to accept it. Toward the end of its newly released, and otherwise very helpful, video on how to select an EHR is the test question: “What is the ‘best practice’ in terms of the number of patient visits to schedule during the first week of operation with your new EHR?”

Why does the AMA think that the correct answer “A”?:  “Reduce the number of patient visits by up to 50% for the first week to allow you and your staff to learn how to use your new EHR.”

Why isn’t it “D”?:  “Your new EHR was carefully selected to fit into your practice smoothly and seamlessly. There should be no impact on patient volume that first week.”

Why does the typical EHR implementation follow the bottom line of the graph below, when it should look like the top one? Dr. Jacqueline Fincher’s testimony at last week’s HIT Policy Committee’s hearing on “Experience from the Field” is representative of the all-too-common experience.

Dr. Fincher reported an “absolute requirement to drop patient volume by half for the first three months [due to] an exponential learning curve,” and that she and her partners “have never gone back to the previous volume of patients,” even after 5 years of EHR use.

Some argue that the medical business is different from other industries like banking and shipping. That is very true. The type of data collected is different, and the level of employee responsible for inputting much of the data is also very different. In most industries, it is the lower-level, less costly employees (such as bank tellers and UPS truck drivers) who input data, while in medical practices, it’s actually the CEOs (i.e., the physicians) who do it. This makes productivity all the more critical for an EHR. According to the recent MGMA study on EHR adoption, fear of productivity loss is the primary barrier to EHR adoption—a concern justified by reports from experienced users, as illustrated below.

For the EHR industry to evolve as necessary for widespread adoption to become a reality, choice “A” must be rejected as totally unacceptable by physicians and the professional organizations that represent their interests. Physicians should expect more from their EHRs—they should demand that vendors deliver productivity, not merely fancy features and functionality. The truth is, they can get both, but only if they do their due diligence.

Usability: Can Every EHR Be Above Average?

Usability is the key differentiator between the long-term success and failure of an EHR implementation. The findings of the recent MGMA study lead to the inescapable and troubling conclusion that too many physicians do not consider their EHRs “usable.” A bad EHR choice is costly for the particular physician(s) and, while it might suffice in the short term for the purpose of earning meaningful use incentives, it will do nothing in the long run to foster sustained EHR adoption. Recognizing this, the HIT Policy Committee’s Adoption and Certification Workgroup convened an 8-hour hearing last week on the subject of how to define and measure usability. Recommendations were offered that mirrored my EHR reform proposal, and various groups/studies are already working on usability testing. One such group is CCHIT, which has introduced a usability rating tool into its commercial certification (not to be confused with government-certification) process. In her testimony, Karen Bell, M.D., Chair of CCHIT, discussed the results (Chart 1) and her recommendations.

So what’s wrong with this picture?

What’s wrong is that, to be useful to physicians, it has to look like this:

This is not meant as an indictment of CCHIT—the organization is to be commended for having taken an important first step in defining usability and creating a process for measuring it. The problem—which Karen Bell did acknowledge when challenged about it—is that if this rating scale were an accurate reflection of usability, there would be many fewer complaints about EHRs and, in my opinion, many fewer failures.

To provide physicians with the objective information that will be valuable to them in EHR purchase decisions, the ratings must be comparative and follow a normal distribution, as illustrated in Chart 2 above. Because achieving this distribution would require more aggressive usability criteria, it would distinguish those EHRs that have the greatest positive impact on productivity and cost savings from those that have a lesser, or negative, impact in these areas.

Even more important, this more challenging evaluation will create a market in which vendors are forced to compete on usability and how to better meet the needs of physicians. Physician satisfaction levels will increase. It will elevate quality across the board and raise the level of the entire EHR industry. Perhaps, as Dr. Ross Koppel testified at the Usability Hearing, if health IT were more usable, we wouldn’t even need incentives to spur EHR adoption!

MGMA Study Reveals #1 Reason Physicians Fear EHRs

The evidence is indisputable: the fear of lost productivity associated with EHR implementation is uppermost in the minds of physicians, and their fears are justified by the actual experience of the majority of EHR adopters to date. The titles of two articles about the recently released MGMA EHR survey say it all: “Survey: EHRs Often Don’t Increase Doc Productivity” (Health Data Management) and “HITECH Drives Docs to EHRs, but Cost, Productivity Issues Remain” (Healthcare IT News).

MGMA is to be commended for the size and scope of this important survey (4,588 practices representing 120,000 physicians), for the multiple ways it segmented the survey population, and for the detailed analysis of the results. One important segmentation was missing, however—that of physician specialty, or, at a minimum, of primary care versus specialist. The EHR experience of orthopaedists or ophthalmologists, who may see as many as 60 patients a day, is dramatically different from that of a family practice physician who sees 20.

Productivity was the pervasive issue. The only group that reported some productivity gains was the 16.3% self-proclaimed “optimized users” of EHRs—those who have had sufficient time following implementation to master the EHR. (The report did not define “sufficient time.”) Among this group, 41% reported that physician productivity has increased. What is disturbing about this statistic, however, is the implication of the converse—that even among these most accomplished EHR users, the majority of physicians (59%) are seeing a decrease, or at best no increase, in productivity. For the total population studied, 43% have just worked their way back up to where they were before implementation, and 31% of respondents are experiencing an actual productivity decrease.

Productivity was the major factor accounting for why 8% of survey participants are in the process of replacing their EHR with another, while anticipated productivity loss was reported as the most significant barrier to EHR implementation for physicians still using paper charts. Among these paper users, 78% fear productivity loss during implementation and 67% worry about the effect even after the transition to an EHR.

This data confirms past experience regarding productivity loss and raises these critical questions:

  • Why do only 16.3% of EHR owners categorize themselves as “optimizing their use of an EHR”?
  • While government incentives will certainly address the financing concerns expressed by small practices, how will this money address the productivity obstacle for all adopters?
  • What accounts for the loss of productivity?
  • When technology has replaced an antiquated paper process in other industries, it has always brought increases in productivity. How do we deliver the same results in healthcare?

The MGMA report did not tie satisfaction and productivity to the particular EHR being used, but there were clearly some successes, so it is important to understand what differentiates these implementations. It all comes down to usability. According to a recent HIMSS Task Force Report on why adoption has been so slow, “A key reason, aside from initial costs and lost productivity during EMR implementation, is lack of efficiency and usability of EMRs currently available.” I maintain that lost productivity and lack of usability are one and the same.

Meaningful Use Rule: Initial Comments Set the Tone

It’s been a relatively quiet week—the initial reactions to the proposed rules on “meaningful use” and standards are out, and the flood of commentary has temporarily subsided. The work of reviewing and analyzing the rules in depth has just begun, as staff at various industry organizations pore over the 700 pages of government verbiage at a more detailed level to evaluate how their respective stakeholders will be affected. We are actively participating in such conversations, and a number of leading organizations—MGMA among them—have reached out to us to talk about the implications for physicians. I hope that they will take our input into account as they formulate their recommendations.

Although it is anticipated that the vast majority of public comments will not be submitted until the final days of the 60-day comment period—i.e., in early and mid-March—individual physicians and others have begun formally registering their opinions. Not surprisingly, some of the initial comments reflect anger about the length and complexity of the rules themselves. Urging the government to keep the requirements simple was a common theme among comments from physicians and administrators:

“If the goal is to get the majority of clinics using EHRs and to provide incentive funds to help the economy, then the first step of incentive payments must be easy to obtain.” —Craig Brauer

“The ‘meaningful use’ criteria should provide incentives to encourage the implementation of the most essential features of an EHR, but it is imperative that the ‘meaningful use’ criteria not become a Christmas tree of features that becomes hugely expensive and unworkable. The ‘meaningful use’ criteria must not make perfect the enemy of the good.” —Robert Rauner, M.D.

Others talked about the limitations of traditional EHR products and issues of usability:

“I am concerned that the current emphasis, promoting adoption of existing EHRs, with little focus on the need to make EHRs better, will ultimately slow innovation. . . . Usability is the Achilles heel of current EHRs. An EHR may meet all of the functionality requirements and yet be so burdensome to use that patient care is made more difficult. . . . At this point we don’t need more EHRs, we need better EHRs.” —Christine Sinsky, M.D.

Objections to CPOE and the effect on physician productivity were also common:

“The process of entering orders is often inefficient and time consuming, with multiple screens, drop-down boxes, scrolls, and clicks. Assigning these clerical tasks to physicians results in a redirecting of limited physician resources away from clinical work, replacing direct patient care with low value added clerical work.” —Christine Sinsky, M.D.

To view these and other comments, or to submit your own recommendations, go to regulations.gov.

On a lighter note, a few days ago, I read a parody in HIStalk (a venerable healthcare IT blog) called “Marry in Haste, Repent at Leisure: Choose Your EMR Soul Mate Carefully.” It compared purchasing an EMR to getting married, and the analogy is a good one. Mr. HIStalk, the blog’s author, postulated that “the same handful of wrong reasons that convince people to marry unwisely also convince them to buy EMRs that will make them unhappy.” If you are interested in reading more, go to HIStalk.

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.

Planning for the Flood

I spent the last few days attending the annual conference of the Medical Group Management Association (MGMA) in Denver, where there was a lot of talk about the financial challenges practices are facing and about the government’s EHR incentives.

Robert Tennant, MGMA’s Senior Policy Advisor, acknowledged that few groups will be eligible for the incentives when the government’s program begins in 2011. According to William Jessee, M.D., President and CEO, the vast majority of practices do not currently have any type of EHR, and despite being pressured by vendors that the time to purchase and implement one is now, physicians are reluctant to commit the resources necessary to do so. He attributed this to the financial effects of the recession—an unprecedented negative growth in practice revenue that is resulting in decisions to postpone capital investments. Add to this the pervasive confusion surrounding the incentives themselves, and the forecast is for wholesale inaction.

All of this has reinforced my belief that it is more important than ever for physicians to make good business decisions, and to do everything they can to enhance—or at a minimum, preserve—productivity. Not only will practices be faced with the financial pressures and declining reimbursements cited by the MGMA, but additional factors will make productivity critical. The impending flood of aging baby-boomers and the newly insured (through healthcare reform legislation)—coupled with a growing physician shortage—will swamp the healthcare system. This increased demand for care creates an opportunity, but only physicians who can leverage EHR technology to boost their productivity will really keep their heads above water.