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.

RFP: Relevant For Productivity?

Identifying the right EHR for a practice has always been difficult—there are so many choices; there is no objective information about competing products; you have to rely on vendor-identified references; and there is an abundance of misinformation about what is (or is not) required by the government. To sort out this information, consultants and practices often rely on the well-known acronym RFP—Request for Proposal—even though the RFP process is flawed.

The big problem with RFPs is that they emphasize the wrong criteria. They yield information about product features and functionality, but not usability and impact on productivity. It’s like buying a car with a full set of luxury options, only to realize later that it tops out at 40 miles per hour. What you didn’t consider is “usability.” EHR failure is tied directly to the impact on physician productivity, yet not one of the last 10 RFPs I’ve received—each containing 100–200 questions—has even mentioned productivity. In fact, by their very nature, RFPs cannot evaluate the characteristics most critical to successful adoption because there is no way to objectively measure things like productivity, efficiency, and usability in a written format. This is why practices using RFPs still end up as part of the 50% EHR-adoption failure statistics.

RFPs provide detailed information about product features and functionality; however, here’s what you can’t learn from even the most comprehensive RFP:

  • How long it takes a physician to use the features to accomplish routine clinical tasks—for example, write a prescription, review a chart, or send a message.
  • What the net effect on productivity will be—during implementation phase and ongoing.
  • What the likelihood is of receiving government incentives—i.e., your ability to use the EHR as required.
  • How great the failure rate/number of dissatisfied clients is—from de-installations to clients no longer using the software—particularly in your specialty and practice size.
  • What percentage of customers is not using the EHR fully—e.g., still dictating exam notes and transcribing.

To obtain this critical information, practices must take control of the competitive analysis process. Do your own benchmarking of the number of clicks and time required to accomplish a few simple tasks with each of the EHRs under consideration. To estimate the value of the impact on productivity, input the time difference per exam into the productivity calculator. The insights gathered regarding the comparative merits of EHR products will be infinitely more valuable than the information received in response to a 20-page RFP.

Instead of relying solely on an RFP, use a stopwatch to evaluate and compare EHRs. If you would like a stopwatch, just e-mail your name and address to stopwatch@srssoft.com and I will send you a complimentary one.

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.