The EMR Challange, Part 3 - Root Causes

Now, let's get down to the most basic root cause analysis as to why EMRs do not have adequate implementation. Again, it is primarily because implementation is not adequately valued.
Why? Because most underestimate the scope of implementation and assume it is little more than training.
Why? Because most assume it is little more than just automating what clinicians do now (i.e. just move the paper behind glass).
Why? Because most do not have an experience base to be able to understand the complexity of implementation and the nature of emerging requirements necessitating more comprehensive EMR uses.
Why? Because inadequate implementation resources (time/budgets/interest) are available.
Why? Because most are too overwhelmed just with the complexities and demands of what they have to do now within their current environments.

Every EMR vendor provides options for training. A very few go beyond to offer basic, preliminary implementation tools (project planning, guide of suggested milestones, etc.).
In order to get beyond the current challenge, shouldn't EMR vendors incentivize for greater implementation awareness in some fashion? What are the alternatives?

The EMR Challenge, Part 2 - Current Situation

The current situation is that potential, new users contact an EMR vendor; an EMR is sold with almost no assessment of clinician/practice readiness and with little matching of implementation/training to the practice needs. The end result is that we have an industry situation where greater than >10% new users are less than pleased with the whole EMR thing.
It is also prudent to be aware that recent surveys by both the NEJM and CDC reveal < 10% of medical practices are using EMRs in a comprehensive fashion.
From More on EMR Failures:

"Under these conditions, the relatively small number of very successful installations is not enough to pull the average EHR return into positive territory, and the CBO is right in concluding that “By itself, the adoption of more health IT is generally not sufficient to produce significant… savings”.

Most clinicians just don't recognize it is impossible to expect to be able to use simpler, free text and narrative documentation in a comprehensive fashions, and only a handful of EMRs manage both narrative and structured data well. Unfortunately, almost all EMR solutions designed primarily for comprehensive use (i.e. structured data entry) experience 20-40% de-installation rates, and >80 of their clinician users are not actually using them, comprehensively, at the point of care. The most miserable group of clinicians tends to be those that are using the comprehensive systems, are forcing themselves to troll in the structured data, and typically are experiencing an average of 30% loss in productivity. This has all but become the norm in many (most?) situations where decisions are made by someone other than those in the trenches. Who cares if the doctors are having to spend 2 more hours, daily, creating documentation? As long as they don't see a lot fewer patients, and as long as they are shuttling patient's into the delivery system's profit centers, isn't everyone happy? I wonder if fewer will be happy once the profit centers become less profitable with the coming "reforms," and the practices are then seen more vividly as cost centers? Will we see another cycle of integrated systems unloading acquired clinics again (as was the cycle in the 1990s)? Do you think patients will end up even having access to their own data when this next shake-out happens? When will control of the data become an epic question?
A key challenge, for SOAPware, and the handful of other multi-capable EMRs, is to make efforts to not be seen as less desirable by both clinicians looking for "paper behind glass" solutions and by those looking for an EMR to collect structured data. We have our work to do to demonstrate how SOAPware is an ideal transition tool from simple to comprehensive, and to help end users understand why that even matters.
Due to this confusion by potential EMR users, several industry “experts” are suggesting that SOAPware do what many other EMR vendors are doing and just raise our prices and guarantee the practices will get $44k for meaningful use over 4 years. In order to make this work, we would have to triple our software price and charge around $15k per year for just the software. Then, we could simply plan to pay back $11k to the practices yearly for 4 years if they can't change their styles in order to meet M.U. We would actually be more financially profitable, while costing less than most other comprehensive EMRs, and might even end up with patient data controlled by something that is a little less enamored by their profit centers.
Pretty cleaver... No?

The EMR Challenge, Part 1 - Definition

Let's face it, no comprehensive EMR (which includes adequate practice analytics, registry reporting, connections to personal health records, etc.) vendor has an adequate implementation process that will allow for >90% of users to be able to adopt the advanced functions. What makes this especially challenging is that few adequately understand what adequate implementation planning/guidance even means. So, the current situation is that the EMRs that clinicians are actually using at the point of care are not comprehensive (e.g. SOAPware v4 and similar) because these require less implementation planning/guidance than more comprehensive/capable EMRs (i.e. SOAPware 2010). However, emerging EMR requirements (being met by SOAPware 2010) are much more complex and demanding.
Emerging, comprehensive EMR functionality requirements (mostly set by non-users of EMR) often exceed what EMR users can initially adopt without adverse disruptions to patient care. Therefore, clinician EMR users tend to gravitate into one of 3 groups:
1. Use simple EMR, as paper-behind-glass repository of narratives and free text, and remain unable to meet emerging requirements for more comprehensive use.
2. Use comprehensive EMR to capture more structured data and accept adverse practice disruptions (average 30% loss in productivity, reduced patient interaction, clinicians become data trolls).
3. Acquire comprehensive EMR, and accept clinicians will not actually use it at the point of care. They continue dictation/paper and leave EMR interaction to others.

My current career passion is to oversee the creation of a suite of comprehensive EMR implementation products/services allowing >90% of clinicians to adopt advanced, comprehensive EMR and advanced H.I.T. functionality at the point of care while increasing everyone's satisfaction and productivity. The scope of the challenge is about to be more clear once the ARRA "meaningful use" criteria are finalized. It appears these are likely to be complimentary to the specifications for the Patient-Centered Medical Home (PCMH) specified by NCQA.

Health Insurance Reform

O.K. I have held off as long as I can in making comments about recent events. We have seen a 2,700 page bill (Patient Protection and Affordable Care Act) passed that shifts, somewhat, who/how health care products are purchased and does little to change the product itself. However, it is true that it includes some initiatives to change the product, but in a top-down fashion. Top-down is an approach that all of history confirms is fundamentally flawed. How much more evidence do we need? Real health care, rather than health insurance, reform has to come from the bottom up or it results in just another system of games, and manipulations in order to get a bigger piece of the public coffers. At the least, we can look forward to a more complicated gaming system.
Anyone who believes the CBO forecasts of lowered costs is delusional. Again, the plan doesn't promise much effectual change to the product itself which contains 40-50% waste comprised of:
- Defensive Medicine – 30-40%
- Administrative Costs -20-30%
- Products and services not improving outcome – 10-30%
- Duplicative Services – 10-20%

Certainly, I am pleased to see that 32 million people will theoretically have more access to care. Extending the social contract appears to be an immediately, honorable undertaking. However, how honorable is it if it saddles our children with insurmountable debt combined with a pervasive sense of entitlement? Amazingly, it has already started. This is a true story... from an M.D. on 3/23/2010:

“A guy called my office today wanting to schedule his "free complete physical."  I kid you not. He yelled at my receptionist when she explained we didn't provide free physicals. "Don't you people listen to the news?! The President signed free health care into law yesterday." He ended by threatening to report us to Consumer Affairs.”

Actually, there are some hidden gems of opportunity to positively change the system that are hidden deep with the pages of the legislation. Once the politics plays out a bit, and key players are named, I will post some comment.

If you need a tax break, have a baby?

Excellent article - E-Medical Records: 10 Steps To Take Now at InformationWeek Healthcare.

It includes discussion of the following:

1) Get buy-in and sponsorship from your organization's top leadership, including influential clinicians and the CEO. "Solicit your leadership team and actively communicate with upper management,"

2) Decide how you'll fund the project--remember stimulus dollars don't start flowing until 2011.

3) Start evaluating your workflow and processes. Figure out what steps you're doing now waste time and money, and can be eliminated with the new system.

4) Find out where key information resides in your organization.

5) Look at EMR and other health IT products for the ones that fit your organization's needs.

6) If you're not ready for a big bang approach to EMRs, consider modular software and components that let you add functionality in increments.

7) Determine whether you have the resources and staff to handle an on-site system--both to implement it and keep it running.

8) Get your infrastructure ready to deal with new systems.

9) If you were already planning or implementing health IT systems prior to the HITECH legislation passing in February 2009, don't change things now.

10) Finally, don't jump into poorly thought out health IT plans just to try getting the stimulus rewards. "Don't do it just for the money," said Wilson. "It's like having a baby just for the tax break."

How about... why don't you marry somebody today so you can have possibly have a baby with them next year for for a tax break for 4 years? Yes, probably about as absurd as expecting the Repubs will do well in November, and then rescind a bulk of the ARRA stimulus funds?

High-Tech and High-Touch

In a recent email thread on a physician list serve, Dr. Lowell Kleinman of Family Practice of San Clemente started what I consider a very revealing couple of lists:

Hi-Tech
1. EMR
2. Portal
3. eRx
4. Staff e-messaging
5. Patient recall
6. Preventive Med pop-ups
7. Practice Website
8. Emailing patients
9. Patient Links
a. "How's Your Health"
10. Physician Links
a. up-to-date
b. FRAX


Hi-Touch
1. Planned visits
2. Call backs
3. High 5's
4. Whole family care encouragement
5. Open Access Scheduling
6. Asking about personal matters


I think this is worth a pause. Which list is most valued by patients, and which is most valued by healthcare policy makers? What is the significance of the difference?
Is it possible that over-focus on the first list sometimes detracts from the second?

It's Not About Meaningful use... From THB

John Moore has yet again cut to the chase and stimulated some great discussion over at the Health Care Blog. I encourage everyone to go there for the full discussion. I could not help but create some excerpts:

...adoption hurdles are not so much about MU criteria, but more about productivity losses in adopting an EHR

...EHR, from one of the big names in ambulatory systems, has been a complete disaster for the clinic.

...The clinic puts the blame squarely on the EHR, which has severely constricted their ability to see patients and as all readers know, clinicians get paid for seeing patients, not trying to use a complex and difficult to use EHR. They are losing money far in excess of what HITECH Act incentives will provide. This story is, unfortunately, not unique, though few EHR vendors will come clean on the productivity hit to a practice.

...Workflow is always a challenge but rarely if ever should one try to code existing workflow practices into a new enterprise software solution be it ERP or EHR. A recipe for disaster. A very delicate balance must be struck between adopting out of the box workflow and customization to existing workflow practices. Careful review of a vendor's solution is required to best match capabilities to needs (doubt many in this industry, esp small practices, have the skills to do this assessment correctly and doubt RECs will be much better).

Then, some real pearls in the comments:

...Many physicians with whom I speak are angry that anyone, including the government, could be so tone deaf as to suggest they should adopt technology that creates even greater economic stress.

David C. Kibbe, MD MBA



...Technology is supposed to help but most vendors don't get why and where they're the problem.

Until we design software and/or devices that take into account the different contexts a clinician finds himself/herself during their daily workflow we will have little success in getting them to implement technology.

Other factors that bring down productivity while implementing an EHR or EMR are:

1. Low clinician buy-in,

2. No clarity or a roadmap that others can follow, the implementors don't understand the needs of the clinicians and the clinicians have no idea what is going to happen next,

3. Lack of training before implementing,

4. Poor workflow analysis, cookie-cutter approach is detrimental to the practice/clinic,

5. Lack of a champion withing the practice/clinic,

6. Poor support, most vendors have very few support people to follow-up on the implementation,

7. Complexity of software, most try to do so much that they end up doing very little,

These are just a few of the ones I have encountered in a career lifetime of implementing software in hospitals, clinics and practices.

The EHR Guy



...According to the top doc at Sermo, 80% of docs feel EHR is good idea but few feel they can afford the upfront/ongoing costs and productivity disruption they inevitably induce.

I feel that the industry would be better served by first implementing the technology that has the capacity to improve care, lower costs, and at least maintain the status quo productivity.

Thomas Schwieterman MD



...I completely agree with Dr. Waldren's analysis. If you look at industries that used IT to computerize the business and realize efficiency, they all automated very well defined manual processes. There are very few of those in health care, and the ones that are standardized enough, like prescribing meds, or billing, have been computerized successfully.

...many doctors come to expect that implementing an EMR is like buying a new car. Sign the check and drive away. It is not. It's more like getting new orthodontic braces.

...I am not sure why, but these very well prepared physicians, seem to understand that implementing an EMR is a process, not a task and they are in for the long haul... They demand training and on site support and often are willing to pay the extra dollars...
At the other end of the spectrum are the physicians that just want an EMR because everybody is getting one, and "would you be so kind to have it installed while I'm on vacation next week?" (real story). These folks will fail miserably and suffer all the way through.

Practicing medicine is probably more complex than flying a plane, and the software to assist in medicine is probably more complex than the software assisting the pilot. In both cases, it takes time to become proficient, and the expectations should be set accordingly.

The Government has asked for input on their proposed EHR certification model. Why not submit your comments, so the Government gets an idea of the prevailing concerns out there?

You cannot affect change unless you make your voice heard.
The comments are public, thus cannot be ignored.

Here is the URL for commenting. You have until 5/10/2010.
http://www.regulations.gov/search/Regs/home.html#submitComment?R=0900006480ab9d0e

Margalit Gur-Arie



...Human factors and making the software work into existing ways of working are usually the weakest point because that requires initial observation and incremental interaction with the users to find out how they would best interact with the system.

Wellescent Health Forums



... This post and it's subsequent thread reveal a truth I have seen since the beginning of my interest in RHIOs and HIE way back in 2003. IT is seductive, everyone thins IT can do things doctors and hospitals cannot. I've used several EMR systems and none of them save time. First of all it turns me into a secretary and I have to assume other peoples' duties. The IT application may improve efficiency by allowing bureaucracy to rule, and also by shifting more of the work load to the physician. One has to delegate many of the systems functionality to nurses and others such as e-prescribing with the physician reviewing and signing off...

Gary L

Back from HIMSS 2010

Well, I’m about recovered from the annual Health Information and Management Systems Society (i.e. HIMSS) conference in Atlanta 2 weeks ago. In the past, it often took me about 4 years to detox from this conference. This year’s conference was the first one that I actually enjoyed. We, at the SOAPware exhibit, were swamped with interest in how SOAPware can be a part of a solution to empower physicians deserving of their patient’s trust.
In the past, having a focus of using technology to empower physicians, and thus patients, seemed to be all but out of place. The conference has typically been more about industry-centric, rather than patient/physician centric solutions. Industry-centric solutions are more administrative in design with an intent to maximize profits. Don’t get me wrong, having solutions that improved quality and patient care were always considered to be the icing on the cake, but never were the core.
I can recall one of the more depressing HIMSS conferences I went to had one vendor of EMR solutions for ambulatory care raffling off a Hummer. They also had a stretch Hummer limousine that burned through a lot of gas during the conference. They used the limo-Hummer primarily to pick up prospective customers and transport them from the airport to their hotels. It was also used to take the same decision makers (i.e. for EMR purchases) to fancy dinners in the evenings. In visiting with several of those decision makers, it became apparent that improving the well-being of physicians and patients was not high in their priority list. Actually, a majority were fairly clueless as to the challenges in the trenches of delivering care, but they could not conceive of their cluelessness as even a possiblity. Even mysister could have seen through what was happening.
Unfortunately, an overwhelming majority of practices that installed the Hummer solution subsequently hummed right into a nightmare of failed implementations.
Interestingly, the "Hummer solution" received multiple (probably even the most) industry awards that year, and just about all the popular entities that rank medical software consistently had this solution at the top of their listings. The subsequent reality revealed this product was so bad that it is now in the process of being abandoned. Once the product actually tanked, another big boy acquired it, and now they are trying to move users to their other latest/greatest "solution."
HIMSS always includes an exhibit hall covering several acres with hundreds of similar “solutions.”
For me, at this year’s conference, the focus and tone had shifted enough that it was actually enjoyable. There were a greater number of conference attendees appearing to be better informed and less susceptible to the payola schemes. There is a growing interest in solutions that, collaboratively, better serve patients. I am even looking forward to the conference next year. It is my understanding that there is a real interest in making future HIMSS conferences more useful for physician attendees. I welcome and support that intent. If anyone identifies any other conferences/conventions that are proving useful for physicians in their efforts to implement more realistic solutions, please let me know.