A Painful Process

EHR Adoption Tough But Worth It

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Practice Management Feature – July 2013

Tex Med. 2013;109(7):31-36.

 By Crystal Zuzek 
Associate Editor

Selecting and implementing the right electronic health record (EHR) system is no walk in the park. It requires due diligence by physicians, buy-in by all practitioners and staff, commitment to training, and willingness to start from scratch and learn a new way of documentation.

While many practices successfully implement EHRs, some fail to get a system off the ground. In fact, marketing research firm Black Book Rankings' annual poll of nearly 17,000 active EHR users reveals that up to 17 percent of health care professionals plan to change their EHR platforms by the end of this year. The survey reports the potential exodus from one vendor to another is due in large part to EHRs' inability to meet a practice's needs, a practice's failure to properly assess its needs before selecting an EHR vendor, and a lack of EHR network interoperability.

Black Book's findings reveal that many EHR firms are overwhelmed by a high volume of implementations and product demand, preventing them from addressing development problems. The survey also shows some popular one-size-fits-all EHR products do not meet specialists' needs and may not continue to satisfy the need for customizable or tailor-made tools.

David Fleeger, MD, an Austin colorectal surgeon and a member of the TMA Board of Trustees, echoes that frustration. He's one of eight surgeons in a subspecialty group that implemented an EHR in 2010.

"My group spent six months to a year customizing the templates to apply to our subspecialty practice and conform to our workflow. The vendor expected us to do the design work, and it was a steep learning curve. I hope that over time more vendors will develop specialty-specific templates so physicians' training time can be freed up a little," he said.

Despite encountering a few obstacles in the implementation process, Dr. Fleeger says the move away from paper records was worth it.

"The transition to an EHR has been beneficial overall. Although it's a painful process to get the system up and running, we wouldn't go back."

EHRs in Practice

An EHR helps the 17 doctors at Premier Family Physicians in Austin organize data and communicate more effectively with patients, says Kevin Spencer, MD. The practice's online patient portal allows patients to conveniently make appointments, pay bills, ask clinical questions, request prescription refills and medical records, and update their conditions and medications.

"The EHR has templates that provide us with clinical reminders. For example, it will notify us if a patient needs an immunization or test. Our system also tells us if, for example, a chronically ill patient hasn't been seen recently. We can then follow up to make an appointment," said Dr. Spencer, a member of TMA's Ad Hoc Committee on Health Information Technology.

The EHR notifies physicians in real time of drug interactions and medication recalls, as well, he says.

Among the benefits of EHRs is their ability to aid participation in the Physician Quality Reporting System (PQRS), a program that uses incentive payments and payment adjustments to promote quality information reporting by physicians. Dr. Fleeger says an outside vendor accesses PQRS data from his group's EHR and submits it.

"Quality reporting initiatives are going to be some of the main drivers of payment in the future, so it's beneficial for physicians to adopt and implement an EHR to make the process easier," he said.

He adds that the group's staff reaped the greatest benefits from their EHR.

"My front office employees spent 20 to 30 percent of their time maintaining, finding, and filing charts; sending faxes; and obtaining labs and x-rays. The EHR has significantly decreased the amount of time they spend doing those kinds of administrative tasks now."

While the EHR improves front office staff productivity, Dr. Fleeger says the technology increases the amount of time physicians spend on medical record documentation.

"We used to spend $800 to $1,000 per physician per month on dictation services. We eliminated that cost, but now we spend more time every day completing our charts," he said.

Do Your Homework

Unfortunately, not every tale of EHR adoption ends happily. An obstetrician-gynecologist group in Dallas sent a letter outlining multiple frustrations and concerns to its EHR vendor in April. The physicians requested anonymity.

They say the vendor billed for services it either never provided or improperly implemented, and is in breach of contract for "improper service and support, substandard training, and outright lies about the product." The physicians say they lost revenue "due to inability to file claims, monies spent paying staff to fix problems … and lost training hours used to repair [vendor] mistakes."

The letter outlines the group's customer service complaints, requests elimination of current and past charges, and asks the vendor to rectify the problems. The vendor responded by notifying the practice it would send a program manager to assess the problems with the system and develop a plan for fixing them.  

One of the physicians in the practice says he hopes problems with the vendor can be resolved because switching to another company would require even more time and money.

EHR satisfaction among users in small medical groups is declining. (See "Undesired Consequences.") AmericanEHR Partners and the American College of Physicians developed multiple surveys from March 2010 to December 2012 and analyzed 4,279 clinician responses. . (See "Clinical Satisfaction With EHRs.")

Dr. Fleeger acknowledges that initial adoption of an EHR is bound to have its challenges, but says some groundwork at the start of the process helps ensure a successful transition.

Before selecting an EHR, Dr. Fleeger and his partners determined how they would access their health information technology (HIT) software. Physicians can choose one of two models: client server or application service provider (ASP). The client-server model features HIT software installed on a server in the physician's office, accessible through the practice's input devices. The ASP model houses software on a remote server, accessible most commonly via the Internet.

 TMA's Electronic Medical Record Implementation Guide: The Link to a Better Future has more information on the advantages and disadvantages of each model. 

"For us, the most logical model was ASP because it allows us to use our EHR at any of our four office locations and to access information with any mobile device at any hospital we work with 24 hours a day," Dr. Fleeger said.

After narrowing down their vendor choices, the group evaluated the top contenders' performance in other medical practices. The Electronic Medical Record Implementation Guide features these two general guidelines for site visits: 

  1. Physicians will learn the most from practices that have used EHR technology for one to two years. Those who have used it less than that are still in an educational phase.
  2. Physicians should only buy a system they have seen operating in a working medical practice. Vendor demonstrations are not enough. 

The guide also covers preparations physicians should make for customized vendor presentations at the practice. Physicians should gather some clinical case studies, provide them to the vendors in advance, and request they use them as illustrations. The practice should ask the vendor to demonstrate how a template for documenting some codes might look, about whether users can create templates, and about the work involved in constructing a template. In other words, the sales presentation should fit the practice's needs.

After thorough research, Dr. Fleeger's practice selected an EHR and solicited the help of an attorney in the contract negotiation process.

"We used a lawyer who was familiar with EHR vendor contracts and was able to add provisions that protected our practice. We made sure we'd have access to patient data in formats that can be easily transferred should the company go out of business, or should we decide to stop using the product. We also made them guarantee in the contract that the system wouldn't be down for a significant period of time without the vendor incurring some financial consequences," he said.

Dr. Spencer and his partners began researching EHRs in 2009 by focusing on vetting the vendors.

"We examined each vendor's financial viability and sustainability and local market share. Once we'd narrowed down our choices, we visited other primary care physician offices to see how the systems worked for them. We chose an EHR vendor that provided good training and had products that were user-friendly," Dr. Spencer said.

Dr. Fleeger compares purchasing an EHR to buying a car. "The contract is negotiable, and so is the price. Physicians don't have to pay the sticker price."

The following questions from the Electronic Medical Record Implementation Guide are a starting point for discussions with vendors: 

  • How long has your company been in business?
  • How long has the product been offered?
  • What were your total sales last year and last quarter?
  • What is your total customer base? Of those, how many are new within the last year?
  • Does the company hold regular user meetings or have user groups?
  • Is your software sold modularly, or does it need to be purchased as a complete package?
  • What functions are available?
  • What operating platform does the product work on?
  • Will your company guarantee in the contract that the software will comply with all current and future federal and state mandates?
  • How are the licenses issued?
  • What is the cost per practitioner (or concurrent user) for the entire package?
  • What does the price include?
  • How much will ongoing maintenance and upgrades cost? 

The Road to Implementation

Once the practice accepts a vendor's proposal, the HIT adoption process moves into the implementation phase.

During this period, the practice needs to focus on redesigning workflow, learning the new software, and moving essential information from existing paper records to the new EHR.

John Lubrano, PhD, founder and owner of Protis I.T. Solutions, specializes in office automation and EHRs for medical practices. Dr. Lubrano, TMA Practice Consulting's technology expert since 2004, coauthored the Electronic Medical Record Implementation Guide.

He says physicians often are unhappy with their EHR adoption when their expectations don't meet reality.

"There's a lot of due diligence that has to happen on the part of the physician. They can't just take a colleague's word for it that the product will work for their practice. That's not really vetting the products in relation to the practice and not setting the expectations properly," he said.

He adds that vendors feel tremendous pressure to provide practices with effective trainers and implementers.

"With the high demand for EHRs, it's possible that not all of the trainers have a lot of experience with the new systems. It's a good idea for physicians to ask how many implementations the vendor's trainers have done with the new platforms," Dr. Lubrano said.

The implementation phase is perhaps the most crucial step of the entire EHR adoption process. The Electronic Medical Record Implementation Guide outlines several techniques that have contributed to the success of EHR implementation, including: 

  • Appoint someone as implementer to coordinate HIT adoption to make sure it moves forward. Physicians should consider bringing in a temporary employee experienced at handling logistics or a consultant experienced in HIT implementation.
  • Monitor costs. After accepting a vendor proposal, physicians should understand that changes made midstream can be expensive. Before making changes, physicians should always ask the vendor how much it will cost and to provide a note revising the original estimate.
  • Take steps to catch up if the practice falls behind in workflow redesign. Depending on level of experience with HIT implementation, the implementer may be able to facilitate workflow redesign. If not, the practice should use a consultant who can move the process along.
  • Develop training sessions that are instructional and foster self-reliance. Physicians should conduct an intensive training session and then allow everyone to start working with the software on their own. The implementer should collect questions and after 10 days to two weeks, have a follow-up session with the trainer or the vendor. When the trainers leave, the staff will have to be self-reliant.
  • Create a plan for moving essential information from paper records to the EHR. Initially, the practice will be living with an electronic system that combines data from electronic and paper records. Some historic information, such as medication and problem lists, should be entered manually. Scanning portions of or the entire paper record into the computer offers an option for incorporation.
  • Develop a uniform documentation format. One of the great advantages of EHRs is they can simplify documentation through the use of templates, which save physicians time by structuring patient encounters and reducing the need for narrative. 

Crystal Zuzek can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.


HIT Help From TMA

For tools to help assess whether a physician practice is ready to adopt an electronic health record (EHR) system and to obtain guidance on choosing a system, visit the Health Information Technology (HIT) page on the TMA website.

Resources include the second edition of TMA's Electronic Medical Record Implementation Guide: The Link to a Better Future, a white paper titled "EHR Buyer Beware: Issues to Consider When Contracting With EHR Vendors," an EHR readiness assessment worksheet, and more.

TMA members can also access the EHR vendor comparison tool (sign-in required).

For more information, contact TMA's HIT Help Line at (800) 880-5720, or email HIT.

In addition, TMA Practice Consulting offers doctors a practice assessment and workflow analysis to start them on the path to adopting and implementing an EHR system. Information is available by calling (800) 523-8776 or emailing TMA Practice Consulting.


July 13 TM PM Chart

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"Undesired Consequences"

Health information technology and health information exchange, when done well, "are essential to our efforts to advance the triple aim – better health, better care, and lower costs," Steven Stack, MD, an emergency physician in Lexington, Ky., and chair of the American Medical Association Board of Trustees, said during a "listening session" on May 3. The Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology hosted the session in Washington, D.C.

"That we are here today is testament both to the successes and shortcomings of the meaningful use program," he said.

"In the positive, meaningful use has spurred rapid adoption of health IT. Without the incentives provided and collaborations fostered by this program, it is unlikely our health system would be adopting these necessary tools as rapidly as it is now. There have also been undesired consequences. Attempting to transform the entire health system in such a rapid and proscriptive manner has compelled providers to purchase tools not yet optimized to the end‐user's needs and that often impede, rather than enable, efficient clinical care.

For these reasons, and as a general observation, AMA is grateful Stage 3 rulemaking has been postponed to allow health care providers and electronic health record (EHR) vendors much needed time to work together to address these shortcomings. Additionally, we believe more flexibility is needed for providers to meet Stage 2 meaningful use requirements to better accommodate the diversity of clinical settings and variation in workflows."

Dr. Stack said AMA has these recommendations "to address EHR usability concerns raised by physicians and take prompt action to add usability criteria to the EHR certification process": 

  • CMS should provide clear and direct guidance to physicians concerning the permissible use of EHR clinical documentation for the purposes of coding and billing. Given the examples described above, the creation of this guidance clearly requires active dialogue with the physician community so as not to further hinder patient care or further erode physician productivity.
  • Stage 2 of the meaningful use program should be reconsidered to allow more flexibility to providers to meet these requirements while the EHRs are better adapted to accommodate the diversity of clinical settings 

To read Dr. Stack's full presentation, log on to the AMA website.

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