One of my regular readers, sent me the following email about the availability of IT help for those implementing an electronic medical record (EMR).

If my conjecture about the mad rush for good quality IT help is correct, then I wonder if physicians will have to choose between experienced HIT contractors that have long waiting lists and may be overwhelmed with demand (particularly if they get greedy about taking on too many clients or have trouble scaling) or try to find a good but inexperienced firm that will be responsive.

Could be an interesting dilemma?

There’s no doubt that a physician’s IT support can sink an EMR implementation just as easily as a poor EMR vendor. I wonder how many failed EMR implementations should be credited to the IT people over the EMR vendors. I still give the lions share of responsibility for failed EMR implementations to the EMR vendors, but a large number are still thanks to poor IT support.

So, yes it is quite the dilemma. Either it’s going to slow the adoption rate of EMR or inexperienced IT people are going to cause lots of headaches for those implementing an EMR. I have a feeling we’ll have more of the later. The reasoning is simple. How do doctors know who is quality IT help and who is not? Answer: most don’t. I’ll have to think about ways in which I can help physicians solve this problem.

I personally believe that many good quality IT help companies will have trouble scaling as is described above. I know there are companies that have done this relatively well, but I personally think that scaling good help (basically people) is the hardest thing for any company to do.

Many people have been arguing that it’s an easier process for hospitals to be able to justify the implementation of an EHR thanks to the new EHR stimulus money. Even more important might be the 5% penalty for not implementing an EHR.

There’s no doubt that there’s a lot of money at stake in a large hospital system that has 100+ practices. You can do the math: number of providers x $44,000 = A lot of money. However you also have to add to that amount the penalties which is basically: Medcare reimbursement x 5% = Even more money.

I’m certain that every hospital in the US is keeping a close eye on these developments. Even large group practices have some of the same financial equations with just a little bit smaller scale.

What I think most people are forgetting is that there’s a reason most of these hospitals haven’t implemented an EHR. It’s not a simple task. We’re talking about getting hundreds or providers with even a larger number of workflows to agree on an EHR system and then implement it across multiple specialties.

I’ve talked about my experience before visiting what I believe is one of the largest EHR implementations in the US of its kind. They have 100 multi specialty clinics and have been working on their EHR implementation for at least 3 years (if my memory serves me right) when I met with them. After all these years of implementing they were still at about 25% implementation.

Not only had they only been able to implement that small percentage of practices, but they were also just starting to butt up against some major resistance based on the first 25% of practices implemented. Add on top of that the EHR vendor’s ability to support such a large implementation and they were running into some real slow downs.

Now I think this practice had made some real progress and had some pretty strong leadership at the top to even get where they were at the time. However, my point is that even with the best of intentions, these large hospital systems are going to have a major major challenge trying to implement such a large number of EHR in order to receive the ARRA money. Certainly there’s a lot of money at stake, but there’s also certain laws of time frames that makes this an almost impossible task to accomplish in the ARRA timeline.

The crazy thing is I haven’t even really talked about meaningful use in this post. I’m just talking about implementing the EHR and getting doctors to use it. Then, what effort will be required on top of that to show meaningful use of an EHR?

Considering most people put current EHR adoption somewhere in the 10-20% range, I found this part of the article on Healthcare IT news pretty interesting:

Fifty-nine percent of providers surveyed said they have already implemented or plan to implement EHRs in the next 12 months but only 17 percent are participating or planning to participate in a health information exchange.

These survey results are really interesting to me since it seems to show a huge shift in people’s plans for EHR adoption. It’s the shift from asking the question “Should I adopt an EHR?” to the question “How and when should I adopt an EHR?”

Of course, it’s one thing for people to say that they are planning to implement an EHR and actually meaningfully using an EHR. I still think there’s going to have to be a lot of work on the following questions:

• Why should we implement an EHR? – To make the final purchasing decision people are still going to want to define the benefits, risks, and costs associated with an EHR
• Which EHR should we implement? – There are 300-400 EHR companies. Deciding which one will work best for a doctors office is still a major challenge.
• How can we implement an EHR successfully? – There’s a lot of details to implementation. No matter which EHR you select requires creativity, grit and flexibility or your EHR implementation is likely in trouble.

Answer these questions and you’ll be a very busy person. That’s part of my goals for this site.

I was just reading through Jamie’s post on EMR and EHR talking about showing EMR “meaningful use” and EMR reporting. She provides some really interesting examples about the challenges of reporting out of an EMR that wasn’t designed to report those various data elements.

This discussion caused me to think about the impact that having to report on meaningful use will have on an EMR implementation. An EMR implementation is hard enough as it is now. Now, not only will an EMR user have to focus on learning all the new EMR functionality and translating their various clinical workflows into an EMR workflow, but they’ll also have to take into consideration the reporting requirements that will be necessary to get access to the EMR stimulus money and show meaningful use.

Certainly some of this planning could be a good thing and probably should have been done regardless of whether a doctor wanted EMR stimulus money or not. However, anyone that’s had to deal with reporting knows that it takes a lot of work and planning to get it right.

It will be interesting to see how much of an impact these reporting requirements will have on the already abysmal successful EMR implementation success rates. Granted, most doctors implementing an EMR won’t properly address these requirements during implementation and will just suffer the consequences of not showing meaningful use when that time comes.

I find it really disturbing the number of stories I read about doctors who have purchased an EMR basically being left to ’sink or swim’ once the EMR purchase and training process is complete. This is not always the case. Some EMR companies really take a vested interest in those who purchase their EMR software. That’s my biggest compliment of the EMR company I work with on a daily basis is that they really did care about us having a successful EMR implementation. I know a number of others who are just as vested in a clinic’s success.

Unfortunately, far too many EMR vendors don’t take a vested interest in a practice and after the purchase and initial training, the practice is basically left to finish the EHR implementation on their own. Let’s take a look at a common example of what happens:
-Clinic purchases EMR software
-Clinic spends a few days training on EMR software
-Clinic sends support request which goes unanswered
-Clinic gets answer to support request a week later

It should also be noted that the few days spent with the trainer is often untargeted and aptly described as a firehouse which mostly leaves those being trained with a huge migraine. Also, it’s worth mentioning that the clinic ends up floundering along for that week they waited to get their support request answered.

Certainly supporting a new EMR implementation is a significant challenge. Many popular EMR vendors have oversold and just don’t have the trained, skilled staff that are needed to support the number of clinics they’re bringing online. That’s not an excuse for the EMR vendor. They should still be held accountable. However, it’s helpful to understand the challenges an EMR vendor faces so you can possibly avoid them.

Like I said previously, not all EMR vendors have this challenge. This being the case, it highlights the need to talk to users of any EMR software you’re considering. Ask them about the type, speed and quality of the support they receive from the company as a current user and what support they received when implementing that EMR vendor. Also, try to talk to someone who recently implemented that EMR software. Much like a new mother forgets the pains of child birth, EMR implementation pains disappear from memory (see my previous post on EMR and Pregnancy). Plus, in most EMR companies the support and training changes over time as employees come and go. The more recent the support experience the better.

At the end of the day, an EHR implementation does require a determination to ’sink or swim.’ However, it’s much easier to swim when you have someone throwing you a line along the way.

I’m sure that many of my readers have experienced the awkwardness of an error happening during the demo or training of an EMR system. I’ve been on both sides of the fence (watching or doing a demo) and let’s just say it’s really uncomfortable for both sides. Those that have experienced it know that the most common explanation for the error is “This is the demo system and so we haven’t finished setting everything up.” Or in the case of the training system, “This is the training system and so with all of the people training on this system it has some errors from those training on it.”

In some cases, this is completely true. When I’m training my staff for an update to our EMR software, there has been a number of occasions where I was just too lazy to set something up on our test database and it doesn’t work quite right. So, it does happen.

The difference between myself (most of the time) and those demoing and training you on an EMR system is that I’ll make note of the problem and make sure that indeed it was something I could easily fix. If I can’t, then I escalate it to our EMR vendor for resolution before we proceed with the upgrade. Those showing you the demo or training you might do the same. However, if you’re training on the system, there’s little chance the fixes they request will be implemented before you implement the system.

Even more to the point is that far too often it’s not something to do with the test or demo system, but is often an error in the program itself. It’s a good idea to evaluate the error you saw. This can be a real challenge since the trainer is often going to blow by the error as quickly as possible. However, don’t be afraid to call them out on the error. This is going to be the heart of your practice. Make sure you really know if those errors were temporary or chronic. Nothing’s more of a pain than regular errors from your EMR software.

I’ve just begun my series listing the benefits of an EMR in a clinical practice, but today I was kind of struck by a post over on the TempDev blog. The post is called “Would You Go Back to Paper?” The following section of an email they received is what struck me most:

I cannot begin to tell you how the loss of EMRs has adversely impacted our work. Please keep up the good work with helping people implement EMRs.

Sincerely,
A Midwest RN

They also have a poll on their post which should hopefully turn up some interesting results. However, this comment from A Midwest RN really made me think about what it would be like to leave an EMR and return to the paper world. I’ve quite often suggested that if the clinic I work for full time chose to move to another EMR, I’d just leave first. I expect if they chose to go back to paper, I’d do the same. Luckily, I don’t think either of those things are even in the dark recesses of the mind.

I must admit it’s really hard for me to imagine our clinic without EMR. It’s such an integral part of how we operate that I can only imagine the struggles we’d have to go back. Sure makes me think about all the complaining that happened during the EMR implementation process. I’m guessing the complaining that would occur if we went back to paper charting would be even worse.

Nice to take a second to look at EMR implementation from a different angle.

I’m often amazed at how many people underestimate the impact that an EHR implementation will affect a practice. Actually, maybe far too many people understand this and that’s why EHR adoption is so low. What worries me is that so many of those people that do implement an EHR completely underestimate the impact that an EHR will have on their practice.

Let me try and make the case about how important an EHR is to a clinical practice. I do this not to try and discourage people from implementing. Instead, I do this to encourage people to take the EHR selection and implementation process more seriously. The decisions you make in regards to which EHR you choose will have lasting impacts on your clinical practice.

Let’s take a look at why this is the case. An EHR is part of EVERYTHING you’ll do in a clinical practice. I can’t think of one part of a practice that isn’t directly affected by an EHR (I’m assuming it’s an EHR and PMS). Everything from how you move patients through the clinic to how you handle phone calls will be impacted by your choice in EHR.

Your EHR will become the center of your universe. This is true for the front desk staff, the nurses, the business office and the doctors. No one really goes unaffected except maybe the janitor, but they’re probably a contract worker anyway.

The reality is that you’re going to spend more time working in your EHR than you do with patients. Yes, that does sound wrong to say. It feels wrong to even type it here, but it’s the reality. However, don’t think that this is something new. You could have previously said that you spend more time doing paper charts than you actually spent with patients. Until we go back to the Little House on the Prairie days with one doctor who didn’t document anything, this will be life as we know it.

Now, doctors shouldn’t think that this situation is all that unique. Technology people often end up spending more time doing paperwork, policies and procedures, proposals etc than they do actually working on tech. I’m sure there’s 100 other examples of similar situations. Of course, the point really is that you’re going to spend a lot of time on your EHR. If you’re going to be spending so much time on the EHR, then it seems like the EHR selection and implementation decisions should not be made lightly.

Ok, still don’t believe me that an EHR is the core of a clinical practice? Think about this.

If EHR isn’t the core of the operation, then why do clinics run so slowly when an EHR is implemented? They run slow, because it is the heart of the clinic.

If EHR isn’t the core of the operation, then why do clinics literally shut down when they can’t connect to their EHR?
They shut down, because it is the heart of the clinic.

I was recently reading a post on EMRUpdate (great EMR Forum) by a man I highly respect who goes by CEOMike. In his long post, he made the following short analysis that I thought was really interesting:

I thought by now you would have figured out EMR vendors are LIARS, making some of the bankers look like choir boys. I have done other posts on the install base claims of vendors. Figure it out 4% (studies show) of approx 400,000 primary care docs is only about 16,000 EMRs in use. Divide that by the approximately 400 EMRs [see my list of over 400 EMR companies] that have been listed in the last three years = 40 users per EMR Or go at the other way – take all claims by EMR vendors and add them up (I did this exercise a few years back) and you get something like over a million doctors using EMRs???

The million EMR installs seems a little high, but the point is well made. How do we really get accurate data about install base? The answer is that you really can’t from most vendors.

When we first implemented our EMR, we were told that they had close to 100 college health centers. Little did they ask (I wasn’t there when they selected this particular EMR) how many of the 100 health centers actually used EMR versus just their practice management system. Let’s just say I was quite surprised by the reality.

That didn’t deter me. In fact, if anything it motivated me to make it happen. Still today I think our clinic is the most cutting edge in our category for use of EMR. I enjoy that feeling and I enjoy when other clinics want to come and take a look at what we’re doing. Yes, I am sure they want to see our EMR and not just have a trip to Las Vegas.

A reader recently sent me a couple personal stories about EHR implementations that I thought worth sharing. I’m not going to say that these are the typical implementations, but I will say that I’ve heard stories like this far too often to ignore. I’ve removed any identifying information about the people, practice or EHR company. This really isn’t about one company, because you could insert any number of names and get the same story. Also, excuse any bad grammar since they didn’t intend it to be posted here, but have given me permission to post it.

Thanks to the reader who sent it to me.

Son-in-law is a family medicine practitioner in a 5 doc group. Wife is a CFNP MSN in an EP Cardiology group. Both here in [CITY REMOVED]. Spouse’s group elected [EHR Vendor] about 2 years ago… at last count of the 12 cardiologists in the group… only 2 were still on board with the program. At least half the problems they have may be due to their unqualified IT plumber who can’t keep their servers running … and when running only at half speed. Typically, they bought the basic package with minor training … someone in their sales contingent also convinced the owning docs that their nurse clinicians could do all the local programming needs … although warned them that if the nurses broke the code … it was their fault. As a result the nurses will not touch anything. [EHR Vendor] (and the local architecture) can’t keep pace with their clinic schedules… wife and the 2 remaining docs who use the EHR spend hours at night and on the weekend doing their record updates because there is no way to do it during the clinic day.

Son-in-law’s group which is owned indirectly via [COMPANY NAME REMOVED] by the [REMOVED] Health System also picked [SAME EHR VENDOR] without consulting any of the docs at any location anywhere in [STATE REMOVED]. His group… one of the biggest revenue wise in the system was chosen as first by the [COMPANY NAME] brains for implementation. Training was provided by 1 [COMPANY NAME] administrator to the ~5 or so admin and business staff … as they were only implementing the business end of the EHR … not the patient record subsystem at this time. On day one… the 5 docs saw a total of 4 patients the first 4 hours they were Hot. With typically 6 patients an hour scheduled … times 5 docs … equals 30 per hour total x 4 hours … equals 120 patients … so 4/120 isn’t even on the chart for failure. They had dozens of patients walk out. Docs were all sitting idle in their offices … and the [COMPANY NAME] administrator and their site manager were pissed at the docs … but the docs just shrugged and said… “we’re here… where are the patients?”. Problem of course was up front where none of the records and pt data was loaded ahead of time so it was like they were all in a brand new practice.

I’ll just let you chew on this one for a little while.