Will Your EMR Installation End Up a Sweet Success, or Will Your Plans Go Sour?

Installing an EMR in your practice is a long, difficult, painstaking process that requires extensive research and due diligence, total commitment from staff, intensive training, and full support from a dedicated vendor. Given all that, plus the severe disruption to a practice’s workflow and productivity that is a hallmark of the installation process, it’s no wonder that EMR installations have a high rate of failure; in fact, the outcome can be so disappointing that more than one in 10 practices decide to reverse course on going digital and return to paper files.

A 2007 survey by the Medical Records Institute—itself no longer in business—suggested that 19% of physician practices had uprooted an EMR or were in the process of doing so. About 14% of respondents surveyed at a conference focused on EMRs had gone or were considering going back to paper. David J. Brailer, MD, PhD, former head of the Office of the National Coordinator for Health Information Technology, once estimated that 30-50% of all inpatient, ambulatory, and ancillary EMR installations fail. As befitting the complex nature of EMRs, the reasons for failure are myriad and varied—practice mergers, vendor bankruptcies, cost, or simply user incompatibility.

Valley Oak Orthopaedics in Davis, CA, which has just three physicians and a physician assistant at two locations, spent $50,000 on EMR software and maintenance over a four-year period beginning in 2004. Administrator Chris Taylor estimates that the practice used maybe 5% of the capabilities of Charting Plus EMR, a product now called MediNotes e, from MediNotes, a company now owned by Eclipsys. “We kind of went into it blindly. We didn’t fully understand the workflow,” Taylor says. “We were using a full-blown EMR as a document management system.” The doctors had made a decision to eliminate paper, but didn’t otherwise change many of their ways. “They still wanted to dictate,” according to Taylor, “but they didn’t want to chase charts.”

The practice took a week off for training when it first installed the EMR, then came back to a full slate of patients. “We should have started back with schedules that were half full,” Taylor says in retrospect. It took until late 2007 for Valley Oak to realize something was wrong. “Almost two years ago, the docs decided they needed to change something,” Taylor explains. They made the choice to abandon Charting Plus at the end of last year in favor of a “hybrid” EMR from SRSsoft, for which Valley Oak pays a monthly subscription rather than hefty up-front licensing fees. Montvale, NJ-based SRSsoft defines a hybrid EMR as one that, like a hybrid car, reduces inefficiencies. In this case, customers select only those modules they need, such as remote access, e-prescribing, order management, or outcomes tracking and reporting.

SRSsoft CEO Evan Steele puts the EMR failure rate at about 50%, based on the number of replacements the company has done. “But in high-performance practices, it’s up to like 80%,” he says, referring to practices with high-volume specialties that produce big charges for each patient visit. “Even the slightest decrease in productivity is magnified,” he says.

That is true at Valley Oak Orthopaedics, where each surgeon might see dozens of patients a day when they’re in the office. “They couldn’t do that with a point-and-click EMR,” Taylor says. They perform surgeries at multiple hospitals and ambulatory surgery centers, and dictate notes at the surgical facilities. The new system gives the doctors remote access to their patient records from any of those locations, something they did not have with the old EMR system. “It’s got to make the doctor more efficient,” Steele says.

What does “meaningful” mean?

Getting an EMR project right will only become more important now that the American Recovery and Reinvestment Act (ARRA) has allocated billions in subsidies for health IT. “Our clients want that money,” Steele says, voicing a sentiment felt across the EMR industry.

Because the SRSsoft EMR does not have many of the features as some of the costlier systems on the market, the company so far has not sought recognition from the Certification Commission for Healthcare Information Technology (CCHIT). SRSsoft even makes a point in noting in press releases when new customers decide to turn off certified EMRs and switch to its product. That strategy may or may not work in the future. The Centers for Medicare and Medicaid Services (CMS) has required CCHIT-certified products for several demonstration programs, but it’s still unclear how federal officials will define the “meaningful use” of a “certified EMR” that will qualify healthcare providers for ARRA funding starting in 2011.

The stimulus removes the cost barrier to EMR adoption, but that may be cold comfort to practices that already have shelled out big dollars on information technology. The Endocrine and Psychiatry Center in Houston ditched a Misys Healthcare Systems EMR two-and-a-half years ago after spending about $100,000 over five years on software, hardware, training, and maintenance. “I couldn’t afford it,” says one of the partners, endocrinologist Rikesh Patel, DO.

Misys, now part of Allscripts-Misys Healthcare Solutions, charged a license fee per user, and the practice, which now has eight physicians, was growing. Also, Patel says, the product did not offer the kinds of online services he wanted, including a portal for patients to view their medical records and test results, request appointments, refill prescriptions, pay bills, or have online visits with their doctors, for which the practice charges a fee. The practice switched to a little known, free, integrated EMR and practice management system called MDBug that relies on advertising. When patients sign up to use the portal, they must consent to have advertising presented on the page, Patel says. He says 600 to 700 patients a month go to the site.

With the online bill paying and, to a lesser extent, the e-visits, Patel says he is capturing $1,500 to $2,000 a month in revenue that otherwise would be written off as delinquent accounts. For this reason, Patel is not so much worried about losing Medicare reimbursements if the product does not turn out to meet the “meaningful use” standard. “Overall, it’s been fantastic for what I want to do,” Patel says. “I have been happy for the past two years and have not spent a dime, so all this talk about how it costs too much to implement an EMR or change over is ridiculous.”

For the transition, Patel didn’t need to buy any new equipment, and the biggest investment was the time for staff training. Even that, though, was not so bad. “It was a lot easier to learn than the old system,” Patel says.

Left high and dry

Having already been through training on a previous system can make an EMR replacement much easier to manage than an original implementation. At Valley Oak Orthopaedics, Taylor actually has few regrets about spending tens of thousands of dollars on a system thatultimately didn’t work out, particularly in a region dominated by Kaiser Permanente and the UC Davis Health System. “It was pretty inexpensive compared to some of our big-system competitors,” Taylor says. “We got value out of it and we learned a lot about EMRs.”

Though it was a challenge for a small, busy primary care practice like Millennium Medical Services in Brooklyn, NY to change both its practice management and EMR software in a period of three months, Chief Financial Officer Loretta Vento says it was helpful that the three physicians and 11 full-time-equivalent staff members already had computer skills. “My docs were trained,” Vento says. They were comfortable with tablet PCs and had a wireless infrastructure in place. “When we went from Amicore to Sage, we were ready.”

The practice went live with an Intergy product from Sage Software Healthcare in December 2007. For the first two weeks, everyone learned the practice management and billing pieces of the new software. The third week, the practice turned on the EMR. “Within a couple of weeks, the physicians were comfortable with the software. Within a month, they were very comfortable,” Vento reports.

Given the circumstances, the transition was remarkably smooth, since the impetus was a failed vendor, Amicore, a much-hyped venture between tech heavyweights IBM and Microsoft and pharmaceutical giant Pfizer. “We really thought that with that kind of backing, Amicore wouldn’t go anywhere,” Vento says. They were wrong.

Back in 2004, Amicore was trying an approach that was relatively new at the time, giving customers an in-house server but hosting the data at its facilities. “Because of the instability of the product in the beginning, it was torturous,” Vento says, and the practice wound up with what she calls a “disastrous” installation. “It was a whirlwind. We were riding a roller coaster for about three years.” The founding partners sold the Amicore Penchart product to Misys in late 2006, but Misys later decided not to support the system anymore, leaving customers high and dry. “We could not go back to paper,” Vento says.

Complicating the situation, Millennium Medical had wanted an integrated practice management system and EMR. While Amicore purported to offer one, the complete product with the PM piece included was just about to come to market when the company was sold. In a crunch, the practice turned to Sage, which had recently purchased the Intergy line from former WebMD parent company Emdeon, and the practice actually was a beta site for Sage. “We got a lot of attention from them in the beginning,” Vento says. There was a short-term productivity drop of 10-15% during the transition, which actually is less than experienced by many practices, and Vento believes the whole experience has been worth the time and effort.

Where does all that data go?

Still, no EMR project, replacement or otherwise, is without headaches. Millennium Medical wanted to find a way to migrate the Penchart data to the new system, or at least preserve existing records for viewing in Intergy. They could not, so users have to flip between systems to see older records. Similarly, Valley Oak Orthopaedics has left its Charting Plus software on its computers to pull up older records.

In the case of Community Care Physicians, a physician-owned, multispecialty group with more than 200 providers in and around Albany, NY, two of the 35 practices in the organization had a “legacy” NextGen Healthcare Information Systems EMR from before they joined the group in 2000-01. They also were the only two practices with an EMR prior to 2005, when the parent organization chose Allscripts TouchWorks—now called Allscripts Enterprise—as the EMR for the other locations.

The first Allscripts go-live was in July 2005, and the installation was complete by October 2006. But the legacy NextGen EMR remained in place until March 2009. “We ran two platforms for quite a while,” says CMO Barbara Morris, MD. The cost of running two systems was too high, particularly because the NextGen EMR ran on Citrix Systems, while the Allscripts product is delivered via a Web interface. This year, the last two practices switched to Allscripts.

For a large practice, Morris says there was a “huge EMR implementation and support system within the company.” Within a month, the “good users” were using advanced features such as data mining and quality reporting. The IT group within Community Care worked withallscripts to extract discrete data from NextGen and translate it to the Allscripts database, a difficult proposition. Morris says the physicians who had used NextGen for so many years had to overcome various psychological barriers more than any technological issues during the transition. “I think it was difficult, but not logistically,” she says.

Find the right solution

Really, it all comes down to usability and physician satisfaction. “It still frustrates me how doctors who don’t know technology spent a fortune on their EMR and didn’t get anything out of it,” says Patel, who has found success in his second time around. “I have had so many happy patients; they tell their friends and family about the new EMR system I use, and my practice has grown three-fold.”

Neil Versel is a freelance writer and proprietor of Neil Versel’s Healthcare IT Blog (http://clinicalit.blogspot.com).