This is the start of a new series of posts that I plan to do over the next week or two. I’ll probably try and space them out so that they don’t overwhelm anyone. However, it’s going to be a series of common EMR implementation issues that I hear over and over again.

This series was prompted by a post on HIStalk by Inga where she talked about her visit to the doctor and his complaints about his EHR implementation. As I read through the list of complaints, I realized that they were all complaints that I’d heard before. If I’ve heard them all before, then they must be pretty common and worth talking about more.

Ideally the discussions in this EMR implementation series will help practices and doctors that are implementing an EMR to avoid these issues. I also know that I don’t necessarily know all the answers to avoiding these problems. So, I welcome others feedback on ways to avoid these problems in the comments as well.

Today’s Common EMR Implementation Problem: Many Unexpected Expenses

I can’t tell you how many times I’ve heard a doctor or medical practice talk about all the hidden expenses that they incurred during their EHR implementation that they didn’t plan for. Here are 3 tips to help you avoid this situation.

Unexpected EHR Expense Tip #1 – Plan for hidden expenses. Add $5000+ to your budget for hidden expenses. Hopefully you won’t have to use it, but if (and likely when) you need to use it you’ll already have it in your budget.

Unexpected EHR Expense Tip #2 – Get your EHR vendor to outline everything and anything they could charge you for. Once they’ve done that, consider putting the list of expenses in your EMR contract so that new expenses from your EHR vendor won’t appear. Here’s just a few EHR expenses that you might incur (and may not expect):
-Up front fee (almost everyone just focuses on this)
-Maintenance Fees (monthly, annually, etc)
-Upgrade Fees (to update your software…these are sometimes called Hot Fixes)
-Interface Fees (both sides of the interface..ie. lab and EMR company)
-Device Integration
-Training Fees
-Support Fees
-Licensing Fees (to license their various databases and/or clinical content)
-Install Fees
-Other non-standard modules – You mean you didn’t realize that the patient portal was an extra $150/month?
-EHR or PMS data migration Fees
-Template Creation Fees
I’m sure there are others that I’ve missed. I look forward to seeing the comments on this. I’ll update the post with other suggestions as they come in. As you can see, EHR vendors can charge you in lots of interesting ways.

Unexpected EHR Expense Tip #3
While EHR vendors can often throw unexpected fees at you, it’s probably even more likely that the other outside purchases you have to make during your EMR implementation will be a surprise. Here’s a list for you to consider the other EMR implementation related fees that might come unexpectedly:
-Server cost (almost everyone focuses on this)
-Software cost (including the operating system or third party software your EHR vendor might require)
-New Desktop/Laptop Costs
-Upgrading Desktop/Laptop Costs – You might find that your existing computers aren’t powerful enough to run the EHR you chose. This is particularly true if you’re using something like voice recognition with your EHR.
-Fax Server
-Fax Server Software
-Scanners – Yes, that is plural and people often start with one scanner and then have the unexpected cost of another scanner because they could really use 2+ scanners. Other times people use a cheap all in one scanner which quickly dies after they start scanning in bulk and they realize they need to buy a $1000+ scanner that can handle the required scanning
-Printers – You’ll likely need a few of these to print our prescriptions, patient education, etc etc etc. Plus, you’ll often need a better printer than the one you have.
-Dragon Medical Voice Recognition – The software, the mic (spend extra for a great one), etc. Some don’t realize all of this costs and doesn’t usually come with the EHR software.
-New Network Ports – You could go wireless, but many like the reliability of a wired connection. This costs to run the lines and cut out new internet connections
-Bigger Internet Connection – This is particularly true with a SaaS EHR setup. You think your current internet connection is enough and then you realize you need to pay for a bigger pipe (internet connection) or possibly even a second “backup” internet connection
-Backup Software
-Backup Hardware
-Off site Backup Service
-Cables – Lots and lots of cables required. Sometimes you even have the cable, but then realize you want a longer one. Unexpected expense!
-Power strips and other peripherals – $10 here and $10 there. This stuff starts to add up. Plus, get ready for things like your mouse to start breaking now that you’re using it a lot more.
-UPS (uninterruptible power supply)
Chip Hart added the following suggestions (Thanks!):
-Practices should purchase 25-50% more laptops/tablets (and/or batteries) than they expect.
-All those laptops and tablets will need a SECURE storage and recharge barn.
-You may be paying a carpenter and electrician.
-Integration fees? Data conversion fees?
-Will you need hands-free headsets for your staff, now?
-Maybe it’s time to get bigger monitors.

Hopefully the above lists will help you plan for all of the various fees that are associated with an EHR implementation. Many of these EMR costs are necessary, but end up being really annoying when you didn’t know they were coming. Check through this list to see if you’ve planned for all the EHR costs.

In a future post, I’ll see if I can’t take the above list and give you some ideas on how you can save on some of the costs above.

I can’t remember exactly where I saw someone talk about the “WIIFM” (What’s in it for Me) principle, but it really is an important principle that when understood can have an amazing impact for good. This post isn’t about whether you should live a life asking WIIFM. I’ll leave that question to people much smarter than me. Instead, I want to look at how applying the WIIFM principle to others can help those working on a successful EHR implementation.

In most cases I’m talking about, the WIIFM should be changed to “What’s in it for Them?” Understanding the answer to this question can help you as an EMR consultant, an EMR vendor or even a practice manager or doctor that’s trying to work through an EMR implementation.

One of the first things I cover in my e-Book on EMR selection (It’s free, check it out) is the idea of getting buy in from those that will be affected by the EHR implementation (that’s usually everyone). One of the best ways to get EHR buy in from people is to understand the WIIFM. It’s not fool proof, but it’s one good strategy for getting people on the same bus, going the same direction.

Let me tell you that there’s always a way to find a WIIFM in an EHR implementation. This list of EMR and EHR benefits is a great place to start. However, many of those benefits can be extrapolated in ways that will show what’s in it for every person in the clinic.

Let’s say for example, that your goal for implementing an EHR is to increase clinic revenue by freeing up chart storage space so you have an extra exam room for another provider. You can then talk about what that new revenue can be used for to improve the clinic. Maybe it could include bonus checks or other incentives. These become tangible things that staff can use to better understand WIIFM in an EHR implementation.

I’m sure many of the nay sayers out there are thinking, but an EHR doesn’t provide those benefits. That’s why it’s so important that you define which benefits your clinic is striving to achieve before you select or implement an EHR. The list of benefits you use to show WIIFM ends up being your goals for your EHR implementation. They can be used to define your EHR selection process. They can be included in the EHR contract so you have some assurance or protection if the EHR vendor can’t deliver on their sales promises. Not to mention, after the EHR implementation you have a way to measure if it was a success or not based upon those goals.

Test the WIIFM principle. Not from an arrogant Me Me Me approach. Instead, step into the other people’s shoes and ask WIIFM. This approach can really help improve any EHR Implementation if applied correctly.

I know I’ve written about ERP and EMR before, but the more I think about the EMR selection and implementation process, the more I see the same issues that are experienced with an ERP implementation.

The one issue that is a bit different about EMR versus ERP is that there are only a small handful of ERP vendors to choose from. However, we have 300-600 to choose from in the EMR world. That’s an important and challenging difference.

However, the similarities to ERP are many. One of the most striking is how the EMR like the ERP is something that’s going to be used and have an effect on the entire organization. As such, the need to manage the participation of multiple stakeholders is so key.

The key to a successful ERP implementation is to have a great project leader.  Someone who is great at working with various departments. They are great listeners who hear and understand each departments needs. Then, they have to be great at making the case for each depaartment’s needs.

The same is true for EMR. You need an EMR implementation champion who is great at listening to all areas of the clinic: nurses, doctors, front desk, billing, medical records, etc. Sometimes this can be done well by a physician lead, but is more likely to be a practice manager, IT support (if they have project management skills), or an outside consultant. 

It’s easy to underestimate the challenge of “herding sheep.” Done right, it can work very well. Done wrong and your clinic is likely going to have the opportunity to try again after the failed EMR implementation.

There are other comparisons worth considering, but this one was striking me today. I’ll be interested to hear stories and experiences from those who have implemented an EMR. Did you have a strong leader to help pacify the different stakeholders in your clinic? 

One of my favorite EMR people, Matt Chase from Medtuity, wrote this interesting comment over on EMR Update.

Times are achanging. I think a recent install is a good example. The group purchased a decently well-known EMR and it failed. So they went with a second well-known EMR and it failed. Both were certified. Both had a very active sales team. The second one flew in some upper level sales people from the coast when there was talk of deinstall.

After spending half of the national debt and a looming closure of the practice, they called in a consultant. He made his recommendation. They did their demo and they asked the really hard questions– show me how to create new clinical content, show me how to create a new template, edit an existing one, how to fax a single encounter to another practitioner, then multiple encounters but not all encounters of a patient, track any lab value over time, send a reminder to a staff member, assign faxes and scans, etc, etc. Their list was very long. They did not want to hear promises and they did not want a canned demo. They wanted to see the software perform the steps that were lacking (but promised present) in their previous software.

The underlying theme here is that practices believe that certification is truly a functional seal of approval. It is not. Secondly, because certification exists and so many EMRs (>450) are certified, it implies a mature product offering– like buying a hard drive or a computer. You can expect certain functionality to be present simply because the maturity of the market would have eliminated the company. Unfortunately, just the opposite is true.
…
Just this week I learned that a very large practice in our town is out shopping another EMR. Yes, they have a certified one, but they certainly aren’t paperless.

Functionality will become the watchword of EMR, not certification.

That’s some interesting projections. I remember one EMR vendor telling me that a large portion of their sales were to existing EMR users. In fact, I think they said that there favorite implementations were existing users that were switching to their EMR. I also love the observation of how much better an organization is at selecting an EMR the second time they do it.

About a month ago, the market finally fell enough for my wife and I to buy our first house. It’s pretty exciting to finally be able to do it since we pretty much tried to buy a house every year since we moved to Las Vegas 6 years ago. Thankfully, we never did until now (although that’s another story).

After purchasing the home, I found myself spending a fair amount of time having to repair a number of things around the house. One day I pretty much spent all day being a plumber as I (and a nice friend) replaced the garbage disposal, fixed a leaking sink, replaced the mechanism (whatever it’s called) in the toilet. Turns out that none of these things are really all that difficult. Although, it definitely had the initial learning curve for me to realize that it’s pretty straightforward once I got into it.

After spending the day as a plumber on my new house, I couldn’t help but think, “I’m doing the job of a plumber and all I want to really do is blog.”

Many of you are probably wondering what any of this has to do with EMR and healthcare IT. Well, I am the EMR blogger who loves analogies (see marriage and divorce, pregnancy, marriage for money, weight loss, and Katherine posted a Lady or the Tiger one that I enjoyed).

The comparison seems obvious to me. There’s a whole lot of doctors out there that really don’t want to be IT project managers. They don’t want to be EMR implementation specialists. They don’t want to be EMR Contract negotiators. They don’t want to be software evaluation specialists. They want to practice medicine by providing care to patients.

Of course, many of you might easily suggest that I could have paid someone else to do the plumbing and I could stick to the EMR blogging like I want. This is absolutely true. I’m sure there were plenty of plumbers that would have been happy to take my money. Unfortunately, they charge an arm and a leg and I like my limbs. Plus, there’s something valuable about having the knowledge of how something that I’m going to use every day is done.

Extend that to doctors. They could certainly hire an EMR consultant to come and help them do their EMR implementation. In fact, my first job doing EMR was partially to solve this issue. They needed someone who could take care of the EMR implementation from top to bottom. If you find the right person, there’s no doubt that it can work very well. However, similar to the plumber, there’s a cost associated with doing that. Plus, if you use a consultant, you’re outsourcing some of the knowledge and expertise that you would gain if you and your staff put your nose to the grindstone and did it yourself.

Plus, while I can’t say that I particularly enjoy plumbing, I have to admit that there really was an amazing feeling of satisfaction knowing that I was able to accomplish a task which I’d never done before. I think many doctors and clinics have had that same sense of satisfaction after implementing an EMR in their office.

Some very interesting commentary from an EMRUpdate thread:

Six-plus years ago, I started my own office and my husband insisted on an EMR – mainly because the real estate prices were so high that he did not want to pay for file storage.

I have posted on this site over the years: early on, I was told I was crazy for picking an Application Service Provider (I think it’s now called “cloud computing”), and the site had a smartest-guy-in-the-room vibe.

But my EMR worked so I didn’t need help or a tech consult. So I went on my merry way and grew my practice – and downloaded quite a few babies, too! EMR was a big deal for me back in 2004; but now I never really think about it. Maybe the reason is that I was never searching for “THE PERFECT EMR” – I picke one that was “close enough” and made it work. EMR has just been a tool for me: I use it and I no longer think about it.

There are a lot of interesting parts about this EMR story. However, the one that struck me most is how now she doesn’t even think about her EMR software. Using the EMR is just completely natural for her.

Reminds me of when I talked to an old family friend who’s a doctor. I told him how I wrote a blog about EMR. After the initial pleasantries he described how he’d been using an EMR for so long (10+ years if I remember right) that he barely remembered what it was like to practice medicine without it. Needless to say, there’s no way he would practice medicine without an EMR.

Of course, for the other 50-75% of the world that doesn’t have an EMR, the question is how long will it take you to reach that level of comfort and what can you do to make your implementation reach that level as quickly as possible. Hopefully the lessons learned on this blog help many people achieve this goal.

A reader of EMR and HIPAA asked the following interesting question:

I was wondering if you had or heard of anyone coming up with a way to measure if the EHR implementation was successful. Other than “its in!”. Im trying to help some clients define this but cant seem to find anyone who has done this. Im thinking something like:
Were all staff trained prior to go live?
Were project goals achieved? etc

Here’s my response that I hope you’ll find useful as well:
It’s an interesting question. I’d suggest you download my free EMR Selection e-Book.

In the book, I cover the various areas where a practice can get benefit from implementing an EMR. I suggest that each practice evaluate which of the benefits they are looking to achieve with their EMR implementation. Then, it works out nicely that it’s the criteria you can use for selecting an EMR and also for measuring how successful the EMR implementation has been.

That’s how I’d approach measuring the success or failure of an EMR implementation. Of course, you could also add in any unforeseen events (good and bad) that happened during the EMR implementation too.

The real key is to establish a set of goals or expectations for what you want to get out of the EMR implementation so you have a way to evaluate the EMR software and the EMR implementation. Then, it’s good to actually look at this criteria after the implementation to see if you fell short of those goals and what you could do to actually achieve them.

Implementing an EMR is a living, breathing thing. The best EMR implementations are evolving and improving as you continue to roll out more features of an EMR or better utilize the existing features. Not to mention all the new features that an EMR vendor will roll out as they upgrade their software.

Dr. Michael Koriwchak recently did a great post about implementing an EMR in a practice with an older physician. He does a great job analyzing the challenge that a group practice faces when one of the older physicians (I prefer mature physicians, but he said older) is the “lone hold-out.” Here’s his suggestion which is really valuable:

So the older doc who claims to be ready to retire may not retire as soon as he thinks. So do you let him opt out of EMR or not?

I would be happy to let him opt out of EMR…provided he commits in writing to a retirement date and allows the practice to begin making plans to recruit a replacement physician. The date would be fairly soon, no more than 18 months in the future. If he fails to retire by that date he would begin incurring costs related to EMR, both in take-home pay and retirement buy out.

This approach avoids the nearly impossible task of trying to calculate the return on investment “break-even point” for an EMR purchase, as many authors try to do.

This is definitely an interesting challenge. In response to Dr. Koriwchak’s post I wrote the following about the mature physician population and EMR:
No doubt there are a lot of interesting dynamics like this in a group practice. I’m glad you’re bringing them to light.

The hardest ones are the middle to upper age doctors that have 5-10 years before retirement. When they don’t want an EMR it’s an ugly situation.

Tell me about your experiences with mature doctors and EMR. Any secrets to be shared?

Honestly, this is one of my favorite discussions to have about an EMR system. The only hard part is that it’s an endless debate with no clear resolution. However, the choices that an EMR vendor makes in regards to their cookie cutter vs. customizable approach is really important.

For those who aren’t as familiar with the issue, the challenge lies mainly in out of the box utility vs. ongoing improvement.

The first part of that challenge is that most doctors think that when they spend their hard earned money on an EMR software, that it should be able to just work out of the box. I think many of the other software programs and other things we buy have created this culture of things just working. For example, it’s amazing how few things you have to do to setup a new computer when you buy it. The computer manufacturers have done a great job making it dead simple to get your computer and be using it shortly after pulling it out of the box.

Most people want this same type of thing to happen with an EMR. Sure, they realize that there will be some customization and entry of their clinic specific data. It’s understandable to have to create some users, add in your address and phone number and a few things like that. However, there’s this expectation that I should be able to just start using the system. Many are surprised when they start documenting their first patient to realize that there are no templates (or insert other EMR feature) available to them for that patient.

Of course, in the EMR vendors defense it’s a challenge to pre-load the information in a way that it just works out of the box. Certainly an EMR vendor could load it up with every template imaginable. However, then they’d hear the complaint that the pediatric doctor had no need for those GYN templates and what kind of silly EMR vendor would make that simple mistake. Of course the EMR vendor knows this fact, but how do you build a software that can take this into account. Much easier said than done.

Of course, some EMR vendors have approached these challenges by providing a real cookie cutter approach to EMR. The complaints then come that the EMR system isn’t customizable enough for the doctor. Of course, these are the same people that would have complained about all the customization they would have had to do if they were just given a really bare bones EMR software install.

The reality is that every practice is different and so it’s a major challenge for EMR vendors to balance these two competing interests.

At its core, the EMR software needs to be as setup as possible right out of the box. However, it also needs to provide as much customization as possible so that when the out of the box features aren’t right for a particular practice it can be changed to fit their needs. It’s a funny little balancing act that has more basis in art than science. However, when done right it makes a huge difference.

What types of things do you do or have you seen to solve these challenges?

In a recent EMR webninar I attended, I heard some really good counsel that was worth sharing here on my blog:

Limit EMR Investment Appropriately, but Don’t Skimp

When people go into an EMR implementation I’ve seen all sorts of approaches. I’ve seen the phenomenally cheap to the no limits buying. Both of those are recipes for failure.

The problem with the phenomenally cheap is that you’re going to end up not investing in the IT products and software that will make a huge difference in your EMR implementation. For example, you might buy a cheap scanner which 2 months later you realize was a horrible idea since you’ve literally burnt through the scanner and it no longer works. Instead, if you’d spent money on the right scanner (which do feel expensive), you wouldn’t have to worry about getting another scanner for 5-10 years (if even then). (See my EMR scanner suggestions on this page.)

That’s just one example. There are many more. Interestingly, the opposite seems to happen when it comes to EMR software. Doctors will spend insane amounts of money on EMR software. I can’t figure out if doctors just don’t realize that there’s a number of very reasonably priced EMR software out there or if they just think that the more they pay for an EMR the more they’re getting.

I guess you could make the case that when you pay more for an EMR you are getting a more robust software platform. In some cases this is absolutely the case. The problem for small practices is that they don’t need or want a more robust platform. In fact, they end up buying this really robust EMR software platform which is so robust that they don’t have the time, money, or energy that’s required to configure the millions of available options and customizations that would make the software great for their clinic. This leaves them with a generally unusable EMR software and an unhappy user of EMR software.

There’s dozens of other examples where doctors need to find the balance between limiting their EMR investment, but not skimping. This is the art of an EMR selection and implementation.