Shopping for an EHR (the second time around)
■ When it comes time to replace a system, learning from mistakes is critical to making sure new technology doesn't bring the same heartbreak.
Michael J. West, MD, PhD, a Washington endocrinologist, recalls when his practice reached the “boiling point” several years ago with its electronic health records system.
“The notes weren't formatting correctly,” he said. “Pieces of charts were disappearing. We would try to fix one part of the chart, and the rest of the chart would fall apart.”
After three months of trying to work through programming issues with the vendor, Dr. West and his practice, which includes another physician, a nurse practitioner and a dietitian, decided to start over again with a new EHR system.
“The new system isn't perfect, but it's 99% better than what we had,” Dr. West said. “Overall, we're pretty satisfied with it.”
Multiple research studies confirm that a growing number of physician practices are dissatisfied with their EHR systems. In March, a survey by AmericanEHR Partners of 4,279 clinicians, including primary care physicians, specialists and diagnostic professionals, found that EHR user satisfaction declined from 39% in 2010 to 27% in 2012. (AmericanEHR Partners maintains a database on EHR products and vendor ratings based on satisfaction reviews submitted by its member organizations, including the American Medical Association.)
The rate of those “very dissatisfied” increased from 11% to 21% during the same period. A separate survey by Black Book Rankings found that 23% of practices with EHRs are unhappy enough with their current system to switch to a new system or vendor.
But when and how do you move from being dissatisfied with your EHR to replacing your entire system? And how do you ensure that your next EHR meets your practice's current and future needs while avoiding the deficiencies and limitations that impede your day-to-day operations?
Deciding whether to purchase or subscribe to a new system requires a cost-benefit analysis of your system and technology needs, said Ron Sterling, president of Sterling Solutions Ltd., a medical practice consulting company based in Silver Spring, Md., and author of Keys to EMR/EHR Success. Perhaps “you bought an EHR, and at the time you had two or three physicians in your practice. Today, you have 10. You are a pediatric cardiologist and your system is not interfacing with the hospital, or your [EHR] provider is dropping a product and forcing you to an alternative system that may not be right for you.”
The time to get a new system is when you have reached the point that “it is more painful to stay” with your EHR than it is to go through the process of replacing your system, Sterling said.
“I would say, think of the long-term damage to your practice if you continue with the system you have and how much harder it will be to switch if you get further into a relationship with an EHR” that isn't working for your practice, Dr. West said.
Before deciding which system to purchase or subscribe to, practice physicians need to understand what is not working with the present system and why.
“There are a lot of factors leading up to the decision that a new EHR is needed,” said Michael Burger, senior consultant for Point-of-Care Partners, a health systems consulting group in Coral Springs, Fla. The purchaser “of a replacement system has the benefit of looking back at the first system and seeing where the stumbling blocks are. A second-time buyer knows what questions to ask and what to look for, whereas a first-time buyer may focus more on price than function.”
Evaluating what's wrong
With their first EHR system, some practices “got what they paid for,” Burger said. “A lot of doctors who looked at EHRs skeptically bought a less expensive product, or one without a lot of features.” Maybe the system was “straightforward and easy to learn,” he said, but several years later, it doesn't offer advanced features like patient engagement tools — portals, population health management, ad-hoc reporting, etc.
Or there may not have been a strong commitment up-front to embrace use of the EHR when the first system was installed. Perhaps physician and staff training participation was “halfhearted,” Burger said. “This has been an enormous challenge for EHR vendors. There's no question that these systems require a new work flow in the office. There has to be a commitment to adapt work flow changes to optimize EHR. Without this commitment, I don't know that the next experience is going to be better.”
Some EHR products were rushed into use — by manufacturers and physicians — to meet federal stage 1 meaningful use requirements, Burger said. As a result, some EHR systems do not save, produce and report records and information as part of a seamless work flow. Instead, the systems require that this data be documented separately, in some cases requiring duplicate data entry.
Finally, for many physicians, their system may not be compatible with their specialty, or it is not effectively communicating with local hospitals.
When doctors figure out that they need a new system, it is important “to have a specific list of what you are looking for,” Sterling said.
Up-front costs, monthly fees and staff training time are important considerations, although you must remember that “you are making a value-added investment” in your practice, Sterling said.
The pricing for EHRs is “variable,” Burger said. “Some are more comprehensive and flexible, and often the more comprehensive the system, the more complex and expensive the system.”
Conversely, “a common practice among the less expensive EHRs is to lowball the costs of professional services,” Burger said. “Perhaps the cost [presented] doesn't include the level or amount of training required to optimize the system.”
Benefits of a cloud-based system
Second-time purchasers always have the advantage of learning from mistakes, if they learn the right lessons. But for EHR buyers, there are more options and resources than there were the first time around.
For example, there are independent reviews on sites such as AmericanEHR Partners. The Dept. of Health and Human Services posts a list of EHR products that are certified to meet meaningful use requirements. Although those pieces of information alone won't tell doctors what systems will work for them, they can give physicians some sense of whether a product is worth considering.
One thing that has changed since the first time many practices bought EHRs is how data are stored. Practices will need to consider whether they are going to purchase a Web-based or on-premise system, Burger said. A Web or cloud system typically has an all-inclusive monthly fee. With the other systems, physicians must assume responsibility for the software, hardware, backups and in-office networks. Sometimes cloud systems seem cheaper because the up-front costs are lower.
“Make sure the cloud is truly cheaper,” Sterling said. “In a one- to three-person physician practice, clouds are attractive. There's a low entry fee, and the system will deal with a lot of [Health Insurance Portability and Accountability Act] security issues.” For a small practice “the system can provide more product than you could afford on your own.”
But for larger practices “the cloud might not make sense,” because fees typically are based on the number of physicians and there are high training costs, Sterling said.
Derek Kosiorek, principal of MGMA Healthcare Consulting Group, believes cloud-based systems offer the greatest opportunity for innovation over the long haul.
Throughout the process, “be a lot more demanding of your new system,” Sterling said. For example, “the data conversion design from your old EHR to your new EHR should be built into the contract, and there should be specifics on how the information is going to be moved from one system to the other.
“Your practice has a responsibility to maintain patient records,” Sterling said. “You can't stop using your current system or stop paying for it” until your new system is fully converted and operational.
Although upgrading to a new system is easier than moving from paper records to an EHR, the transition may take three to six months to reach 100% capacity, Kosiorek said.
“If you are moving from a structural database design to another format, the transition may be challenging,” Sterling said. “As part of the process, you may have to go in and [manually] fix some of the data.”
Throughout the process, look ahead, Sterling added. “The system should add value to the practice” by offering meaningful use features, such as patient portals, recovering and sending lab orders, and managing transition of care. “You want to move beyond stage 2 meaningful use.”
“If [a new system] is not going to be more efficient and easier to use, you don't want to” purchase or move to a new system, Kosiorek said. “It should be viewed as a value-added investment.”