Physicians Spooked by Failure Stories—EHR Adoption Suffers

Physicians Spooked by Failure StoriesA significant portion of the physician market has still not adopted an EHR, despite the lure of government incentives and the fear of the penalties looming on the horizon. The stock prices of most publicly traded ambulatory EHR companies are down sharply, as sales are lower and earnings projections have not been met throughout the industry. How can this be, when the EHR incentive program has successfully increased EHR adoption and was expected to be such a boon to EHR vendors?

I know why, and it is not—as commonly thought—because the initial EHR-adoption rush fostered by the incentives has ended. Rather, it is because of rampant physician dissatisfaction that has reached a more-than-palpable level. I have noticed a dramatic change in the tenor of conversations with physicians, most recently at professional society conferences, where physicians who have not yet purchased an EHR are frozen in their tracks. They are worried by the horror stories they hear from colleagues—even from those who have succeeded at meaningful use—because many of those physicians continue to experience major workflow disruptions and significant productivity losses from which they see no potential to rebound. Recent surveys point to the number of physicians looking to replace their EHRs, and based on my company’s experience in the replacement market, that number is growing. A recent article summarized the findings of a large study on EHR satisfaction and presented an insightful analysis of the potential reasons for these disappointing results.

This heightened level of frustration has resulted from frantic, insufficiently researched EHR purchase decisions by physicians and rushed, inadequate implementations conducted by resource-strapped vendors. Massive EHR failures are exactly what I predicted in an EMR Straight Talk post on the unintended consequences of the EHR incentive program in February 2010:

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. . . . 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.

So, what can physicians do to avoid falling victim to EHR failure, and to instead reap the benefits of successful EHR adoption—government incentives and practice productivity? I have written extensively about the importance of physicians doing thorough and objective reference checking—that advice is as valid now as when I first wrote about it, and perhaps is even more critical today. For guidance on how to conduct a thorough and fair evaluation of an EHR, read EMR Selection: How to Uncover the Truth or 100% EHR Success – A Clinical Approach.

HIT Policy Committee Focuses on Physicians

HIT Policy Committee Focuses on Physicians
A very positive conversation took place at yesterday’s HIT Policy Committee meeting, and it put the focus squarely on the physicians—a focus that in the past seems to have gotten lost in the shuffle.

The Committee was reviewing and finalizing its comments for submission to CMS on the Proposed Rule for Stage 2. A healthy debate ensued regarding who should have to enter the orders into the EHR to satisfy the CPOE requirements—the physician or a designated clinical staff member. In response to a suggestion that there were reasons for requiring the physician to personally enter the orders into the system, Neil Calman, MD, raised the discussion to another level by asking about the entire purpose of EHRs and meaningful use. Dr. Calman challenged his fellow committee members to think about how an EHR should be expected to change the way physicians practice—and how it should not. He asked why we would want to bog physicians down with tasks that other staff were already doing instead of helping physicians focus on the work that utilizes their highest skills and expertise.

The EHR incentives are definitely encouraging EHR adoption, but we should not lose sight of why increased adoption is such an important goal. The value of an EHR to a physician is not the $44,000 incentives—it is the potential for increased productivity and efficiency, better and safer patient care, and the ability to share information. It’s easy to get caught up in creating comprehensive measures that ensure that the interests of all stakeholders are met, and in doing so, to lose sight of the practical impact on physicians’ workflow. In the case of yesterday’s CPOE debate, the committee came up with a recommendation that preserves the intention of the CPOE measure—and meaningful use in general—while respecting the value of the physicians’ time. I hope this conversation will set the tone for future meaningful use deliberations.

HCIT: Don’t Underestimate the Power of CMS’ Carrots and Sticks

Anyone who knows even a little bit about behavior modification theory intuitively understands that offering rewards and/or punishments is an effective way to encourage people to do what you want them to do. The government clearly understands this principle and has been using incentives and penalties to motivate physicians to participate in its programs—PQRS, ePrescribing, and, most recently, the EHR incentives.

The EHR incentives have already prompted a great deal of EHR activity, but the program is too new to quantify cause and effect yet. A direct correlation between government policy and provider behavior, however, is evidenced by the history of my company’s ePrescribing license purchases, so I thought EMR Straight Talk readers would find the analysis of my company’s experience interesting.

As illustrated above, ePrescribing sales tracked the MIPPA legislation as follows:

  • 2009 was the first year of ePrescribing bonuses, and the requirements (a 50% threshold) made it important to start ePrescribing early in the year. As you can see, this created a huge demand for ePrescribing licenses during the first half of 2009.
  • Sales continued in late 2009 and early 2010—although at a more moderate rate—as later adopters decided to take advantage of the last year of 2% bonuses and as the easier-to-meet threshold of 25 ePrescribing encounters was introduced.
  • Imminent penalties caused a spike in sales in the beginning of 2011, when providers first learned that 2012 penalties would be based on ePrescribing activity—or lack thereof—in the first 6 months of 2011.

Another interesting observation that can be made is that, for some providers, penalties are a much more effective behavior modification tool than incentives, regardless of the relative amounts of money at stake. My experience with ePrescribing—illustrated by the 2011 surge in licenses—was that many physicians who had not been persuaded by the 2% bonuses in 2009 and 2010 felt compelled to move ahead when faced with a 1% penalty for 2012. Regardless of whether a particular physician attributes more weight to the carrot or to the stick, the data above—although not unexpected—confirms the effectiveness of the government’s strategy.

ePrescribing 2011: The Irony and the Ecstasy

The number of different government programs, and the length of the rules that describe how to take advantage of each of them, can be overwhelming. But one thing is eminently clear: the importance of ePrescribing in 2011. There are three compelling reasons to ePrescribe in the coming year:

  1. Physicians can earn a 1% bonus on their 2011 Medicare revenue. Aside from the patient-care and physician-efficiency benefits that ePrescribing offers, ePrescribing on at least 25 unique Medicare encounters in 2011 will qualify a physician for an additional 1% of that year’s Medicare Part B Fee-for-Service revenue under MIPPA (Medicare Improvements for Patients and Providers Act). That money would be received in the fall of the following year.

  2. 2011 ePrescribing activity protects physicians from the Medicare ePrescribing penalties in 2012 and 2013. Odd as it sounds, while bonuses for 2012 and 2013 will be based on successful ePrescribing in each of those years, penalties for those years will be assessed based on 2011 activity. To avoid penalties in 2012, (1% of Medicare revenue), physicians must report ePrescribing on 10 unique Medicare encounters between January and June, 2011. To avoid penalties in 2013 (1.5% of Medicare revenue), physicians must report at least 25 times during the full 2011 year.

  3. ePrescribing is a great way to begin the transition to an EHR, particularly if a physician intends to participate in the EHR incentives program (ARRA). ePrescribing is an integral part of the Meaningful Use requirements and—with the right software—a great way to begin the transition to a digital office.

Based on the above, I offer a few strategies for consideration. The rules, and the interplay between them, have created a number of consequences, that intended or not, can be used by physicians to their financial advantage:

  1. It is important to start ePrescribing early in 2011. Ironically, even if a physician meets the 25-prescription minimum and earns the 2011 incentive, he or she would still be subject to a penalty in 2012 if that ePrescribing activity—no matter how extensive—occurs only in the second half of the year. So at a minimum, ePrescribe 10 times in the first half of the year and 15 times in the second half.

  2. Since the rules (MIPPA and ARRA) do not allow collecting under both programs during the same year, physicians can maximize the combined revenue by earning the ePrescribing bonus in 2011, and waiting to begin participation in Meaningful Use until 2012. Beginning in 2012 still allows a physician to qualify for the full 5 years of EHR incentives ($44,000 as a Medicare provider).

  3. Another irony is that, although ePrescribing is integral to ARRA, it is possible to satisfy the measures for one program and not satisfy the requirements of the other in any particular year. The requirements differ, and the onus is on the physicians to meet each set of rules to qualify for the respective incentives.

As confusing as the above appears, it is actually even more so, because there are also some exceptions. Not surprisingly, there are organizations (MGMA and AMA, for example) actively petitioning the government to reconsider the basis for 2012 and 2013 ePrescribing penalties and asking for harmonization of the MIPAA and ARRA regulations. For further information on the implications for your practice, I invite you to take advantage of the educational resources available through SRSsoft by calling our Government Affairs Department: 201-802-1300 X 1229.

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.

EMR Adoption: Why Are You Still on the Fence?

A growing number of physicians—particularly specialists—are no longer on the fence when it comes to the government’s EHR incentives. As evidenced by a recent spate of articles and blogs—one of the more compelling ones being “Is HITECH Working?: Key Physicians Will Sit on the Sidelines (At Least for Now)”—they realize that the costs outweigh the benefits. Physicians have decided that they:

  • Will not buy the type of EMR that is difficult to use and has not worked for other physicians in their specialty;
  • Will not risk the costs of a failed implementation;
  • Cannot tolerate the decrease in productivity—seeing fewer patients and generating less revenue;
  • Have established as a priority improving the quality of patient care they deliver, rather than collecting and reporting data that the government wants;
  • Cannot afford to take on unnecessary additional administrative burdens in the face of declining reimbursements;
  • Are not worried about potential penalties that will be relatively small, if they are even imposed at all; and
  • Are not interested in the government’s program, the benefits of which accrue primarily to other stakeholders, and not to their practice.
So why are these physicians, who have determined that government incentives are not relevant or achievable, still on the fence about adopting an EMR solution that will deliver measurable benefits? Staying with paper charts is not a good business strategy because there is nothing more inefficient!
  • The costs associated with the excess staff needed to manage these medical records are massive and wasteful—these positions can be eliminated or the employees can be more effectively used in revenue-generating or patient-care roles.
  • Paper charts hinder practice growth because adding physicians requires a proportional increase in support staff—medical records, billing, nurses, and medical assistants—and because physicians can’t see more patients without lengthening their work hours.
  • Slow responsiveness to primary care physicians limits referral volume.
  • Profitability is further affected by billing bottlenecks that delay revenue collection.
  • The chaos associated with trying to manage paper charts has a damaging effect on staff morale and creates rampant frustration among patients, physicians, and staff.
  • Paper charts are a malpractice nightmare—prescriptions are not consistently documented, orders are not easily tracked, and medical decisions are often made without complete clinical information.

You cannot afford to maintain the status quo.

Physicians can transform their practices without the government—there are excellent EMR solutions available, such as the hybrid EMR. It’s time to become digital. It’s time to get off the fence!

Healthcare Reform: Get Ready for the Crush!

Against what seemed to be insurmountable odds, President Obama has signed a healthcare reform bill. While the full impact of the bill won’t be known for a while, two things are already clear about this legislation’s effect on physicians. There will be a sharp increase in demand for their services, and they will get paid less for the services they provide—making physician productivity vital.

By 2014, all Americans will be required to have health insurance. A whopping 32 million people will be added to the rolls of private health insurance plans over the next few years with the help of government premium subsidies. Because these people have not had health insurance in the past and many have medical problems for which they have not received treatment, they can be expected to seek care in greater-than-average numbers. Compounding this demand will be the seismic shift in demographics caused by the aging of the 79 million baby boomers, the first of whom turn 65 next year. Their naturally increasing demands for medical care will further stress our healthcare delivery system. Given the current, and growing, physician shortage, physicians will be deluged with patients.

With a projected cost of $938 billion, much of the funding for the legislation will come from cuts to Medicare, which will include payment reform—a euphemism for reduced payments for the services provided by physicians.

Physician productivity has always been important, but the healthcare reform legislation has made it critical. To meet the crush of demand for care, and to grow—or even maintain—their current incomes, physicians will have to see a greater number of patients and do so more efficiently. Now—more than ever—it is important for physicians to invest in software that is physician focused and designed with physicians’ workflows in mind, to ensure that it will increase, rather than decrease, their productivity.

Reminder: to find out what your time is worth, try the physician productivity calculator.