Dr. Bertman Answers Your EHR Questions

In April, HCPLive hosted the live webinar debate Small vs. Large EHR Vendors: What’s Best for Your Practice. Jonathan Bertman, MD, representing small EHR vendors as the president of AmazingCharts, debated Justin Barnes, representing large EHR vendors as chairman of the HIMSS EHR Association. Dr. Bertman and Mr. Barnes addressed relevant challenges and questions, while also engaging in a lively debate on the merits of large vs. small EHR vendors and how practices can determine which vendor best suits their needs.

Although the popular topic brought in many questions from participants that the debaters were unable to get to, Dr. Bertman has since taken the time to answer them (Justin Barnes was unable to do the same). Read on to see what he had to say, and please feel free to ask you own questions.

*Look for audio of the follow-up interview with Dr. Bertman to be posted shortly as a collection of podcasts.

Which sites, if any, do you believe give a practice the most objective help in choosing a system's features? -Carl Bergman

I think the AAFP website is good, and doing a Google search for survey studies will bring up actual articles, such as the Family Practice Management EHR User Satisfaction survey where thousands of EHR users rate their system. KLAS also has ratings, but I’m a little concerned that the data might be suspect (even though Amazing Charts gets the #2 rating) since we had to pay them to get some of our people interviewed. Pay to play is a set up to have those paying more do better - so it certainly creates doubt in my mind as to whether their research is objective and unbiased.

How can you tell if an EHR is good for you when you are starting a new practice? Even if you do your homework and investigate, how can you evaluate it, if there is no consumer orientation?-Gloria Cuellar

The biggest thing is that you need to be able to try the EHR, risk-free, to really know. Her point—which is, “Unless you actually use it in your busy practice, how can you be sure it really works?”—is absolutely correct, and is the main reason that more than 1 in 3 EHR implementations fail. I think selecting an EHR that provides a free trial of their full software, or provides a risk-free money-back guarantee is critical. It’s just too great a risk to sign on the dotted line after seeing a few demos by trained sales people. It’s asking to lose a lot of money. To tell if an EHR is good, you must be able to use it in your practice and see if it takes you longer to write good notes, or actually improves you documentation and overall efficiency. If you immediately recognize the benefits of the system in your practice - without having to "book light," you have a good EHR. If you have to "book light," and finish your notes from home or after hours, you have a lousy EHR. (The User Satisfaction studies in FPM and Medscape summarize the opinions of thousands of EHR users and you can get a good feeling for which systems are usable and well designed.)

How much physician use and feedback is included in the certification process? Many systems I have reviewed have little similarityto usual physician charting.

-D Clowney

That’s one of the big problems with CCHIT. It has not focused at all on usability, and even now as they’re starting to discuss how usability can be brought into it the judges are simply asked “does it look like it’s easy to use with not a lot of clicks?” There are surprisingly few actively practicing physicians on any of these certification groups, and that’s a critical, huge problem that has not been addressed. So, certification, I think, just speaks to the bells and whistles something has but does not at all speak to if something is actually usable.

Why can't the physician component be designed for physician use and not made over billing?-D Clowney

That's a great question that seems so obvious, but is shockingly overlooked. I think it’s because not a lot of EHR have been designed by physicians. The companies that have physician owners, such as Amazing Charts, eMDs, SoapWare, Praxis consistently end up getting higher User Satisfaction ratings than non-physician EHRs, and I think it’s clear why: physicians dictate how the program’s going to run, rather than the businessman owner and programmers whose focus is more on the business side of medicine and not the practice and art of medicine.

Why is usability such a challenge for EHRs?

Again, it has to do with who is in charge at the EHR company. Most of the EHRs spending tons of money on ads and marketing, like Allscripts-Mysis and NextGen, yet getting below average User Satisfaction ratings—tend to be either publicly created companies or are controlled by venture capital and business people with no experience practicing medicine, and I believe their motivation is, “let’s build a product to make money.” I’m obviously very biased, but I think the reality is you need an EHR that’s designed and owned by physicians and whose bottom line is not about making as much money as possible, but rather making the practice of medicine better.

Why is HITECH working? If not, why not?

HITECH is a flawed concept. Essentially, the government has seen that EHRs are not being adopted, and that one of the main reasons is due to their cost (the other being they are too complicated and hard to use in practice). Unfortunately, our government has decided, to just throw money at the problem rather than encourage market forces to lower the price point and improve the quality. Since the average cost to adopt an EHR is said to be about $40,000, the government has decided to use our tax dollars to provide this money to physicians adopting an EHR. And while this is terrific news for lower priced EHRs, as physicians can get the money regardless of EHR price, it completely overlooks the second problem with why EHRs aren't getting adopted - mainly that most of them are difficult to use in a busy practice. So whether or not it’s paid for by someone else, whether or not the program’s free or cheap or whatever, the bottom line is if it’s not user-friendly and easy to learn and use, it’s going to fail, even if the practice has not had to pay for it. By ignoring usability, HITECH encourages less-well informed practice to just buy something, and only after it is too late will the practice realize they've signed a long-term contract for a lousy piece of software.

Is it true to say that larger EHR Vendors charge a higher fee for the initial license and continuing license fee and charge extra for otherservices added on compared to smaller EHR vendors and conversely have a poor support track record.-Tasneem Doriwala

I'm not sure how one should define a "large vs small EHR vendor." Is it a vendor with a large market cap? Is it one with a lot of physician users? Is it one with a lot of unique practices? I think there are expensive EHRs, and there are less expensive EHRs, so I think you have to decide how much you are willing to spend on an EHR, and then look at the list of those EHRs that get high User Satisfaction ratings, go from there. (EHR vendors are a sneaky lot, and I firmly believe that any company that doesn't openly post their pricing on their website should be avoided altogether. The only reason I can think of not to have transparent pricing is because the company focus is to take as much money from you as they can.) Once you've picked some vendors who meet your price-point and User Satisfaction criteria, the next step is to look at their support track record, which is also addressed in these User Satisfaction studies. For example, the AAFP's Center for Health IT, Medscape.com, and Family Practice Management magazine all have recent surveys of thousands of EHR users and in each of these the respondents are specifically asked about their EHR vendor's support. Surprisingly, in study after study, the lower priced EHRs tend to have both a higher usability rating and a higher support satisfaction rating. Go figure.

Should the various vendors who provide EHRs have a rating based on CCHIT standing, regarding the parameters of thefunctionality of the program and the key elements that enbale physician practices to want to buy the system and use it?

-Tasneem Doriwala

I'm not sure I understand the question, but in terms of functionality CCHIT doesn't speak to whether one program has more or less features. That is because an EHR vendor must pass 100% of CCHIT criteria for functionality and features, or it fails. So, if a vendor is CCHIT certified, you know that vendor has 100% of the functionality that CCHIT believes is necessary to be a certified EHR - though that speaks nothing about whether the EHR is usable. Because of this, and because I think many of the CCHIT requirements actually make EHRs less usable, I don't think CCHIT certification should be an important factor in ones decision on buying an EHR. You should get an EHR based on what’s usable, and if it’s certified, great, because it’s more likely that that will be eligible for stimulus money, but still, that’s no guarantee. It still has not been defined as to how you’ll get stimulus money. For example, Amazing Charts got certified because I realized that we were getting excluded from lists just by the nature of not being certified. But the reality is, we had to add lots of silly bells and whistles to the program, and pay over $35,000 for the application fee alone. And then we had to raise our prices a bit - so I believe CCHIT certification actually hampers the ability to have usable and affordable EHRs. Pick an EHR that you find usable and that you can try out in your practice without risk. Forget whether or not it’s CCHITcertified.

What are the 5 most important things that one would take and compare between Large EHR and Small EHR vendors?-Tasneem Doriwala

User satisfaction is by far number one. If the EHR’s users are happy, there’s a good chance you’ll be happy. If 20% or 25% of the users say they were not satisfied, that should be a huge warning, and again, if you look up the Family Management Practice Survey at the AAFP, they have that clearly delineated.

Affordability is number two. There’s no point in buying something that makes you "house poor." If you have to take out a lease or loan, or spend more for your EHR than you would for a car, then you are being foolish. Period. What is becoming clear is that the overpriced EHRs being purchased are being selected by administrators and practice managers rather than individual docs who are the ones who need to use the system day in and day out.

That leads to number three: don't let somebody else pick your EHR. Non-provider administrators have no idea what you do day in and day out to get through your schedule and the many patient issues and decisions that are rapidly made and must be rapidly documented.

Number four is the vendor's user-friendliness. Here I'm speaking about the vendor's website and information. How easy does it feel to get on their website and learn about their products, pricing, and company decision makers. Does the vendor provide easy and user-friendly access to the questions you have, or are you forced to submit fields of information or force you to physically connect with their sales person to get the information you want. (These are all sales games, and when dealing with a company like this, be prepared to get gouged.)

Number five is the timeless admonition from the poet, Carlton Douglas Ridenhour (aka Chuck D): Don't believe the hype. There is a ton of marketing and advertising regarding EHRs from vendors, government agencies, insurers, even IPAs. Don't believe the hype, spend a bit of time doing your own research, and you won't end up in the group wasting thousands of dollars on software that makes the physician's life more difficult.

Physicians are poor businessmen in general. We're generally not going to have the time or knowledge to pick the most appropriateEHR. As a solo physician, I need an affordable EHR with available training that I can trust. I think the company needs to have aquestionnaire to guide me to what I need and what I can expect, rather than leaving it to me to fail in picking a product, and not beafraid to say that their company is better for my practice or that X compnay would be better for what I need, rather than just trying to sell a productthat's not going to work just to make a buck for a salesman. What would you say to such an idea?-Bryan Evans

That is the ideal situation, but where capitalism and sales end up in conflict. We may not be good businessmen, but we are good at analyzing data and making a logical and informed decision. Just like you can't trust a drug rep without verifying the data, you can't trust an EHR vendor - no matter how friendly and warm they may appear to be. You need to find the most objective and "unbiased data and go from there. That is why looking at EHR User Satisfaction survey data from thousands of other physicians who have spent time and money, and now report their feelings and experiences is so critical.

Please, which is the best/number 1 EHR for pediatricians and small practice (ie, four providers)?-Oscar Sugastti

Amazing Charts. Seriously, though, while I do believe we are the best, I know the people from SOAPware, e-MD, Praxis, etc., would disagree vehemently. Each vendor would say - and believe - they are the best. Thus, you can't ask a vendor that question. You have to ask colleagues who have no financial incentive to encourage one vendor over another. Again, it gets back to the need for large survey studies of actual EHR users. That is the list from which you should begin your search. That said, if I was evaluating software for a four-doc practice, I would look at Amazing Charts, SOAPware, eMDs, eCW, and Praxis, since these companies consistently do well on User Satisfaction studies.

What's best for my practice? We are a two-physician, shared, community oncology practice and need a list of 5-10 CCHIT vendors that are only oncology specific. Where do I go look for this list?-Varsha Sharda

I would disagree that you should narrow your search to just "oncology-specific" EHRs, as I think that is much less critical than you might imagine. For example, I would say Amazing Charts is not oncology-specific, but we do have over two dozen Heme/Onc practices who use us and like us. I think you should find an EHR based on how easy it is to use, how affordable it is, and then try it out in your practice to decide if it will work for you. The other place I would look to is your specialty academy association. They may provide data on what other academy members are using, and better yet, could provide survey data on how these members like their EHR (this is what the AAFP's Center for Health IT does).

Do you think that programs like Practice Fusion, Amazing Charts, CareCloud, and others will take over EMR in healthcare due to low price, the cloud, and other Web 2.0 features (like Google, Twitter, and Facebook have taken over the Web?)-Robert Varipapa

First let me clarify that Amazing Charts is a client/server model and isn't hosted in the cloud (aka web based) as is PracticeFusion or Allscripts-Mysis MyWay.

Of course I'm biased, but I believe that physicians should maintain their data locally. While, in theory, the web-based "ASP,""Saas", or "cloud" model sound good, the reality is that your charts are only accessible if your Internet is working and the company continues to offer it. Can you imagine if your office charts were locked up, and there was just one key, and the person with that key was - rare as it may be - late or out for a day? The disruption would be significant and frustrating. Now think of the times you've been unable to connect to the Internet, or experience bizarre unexplained web page loading issues - rare as it may be, and you will get a taste of having a remote EHR database. Anecdotally, we've had clients switch to us after using PracticeFusion and other cloud-based EHRs. Their biggest complaints have been that the delay to open the screens and jump from window to window is significant and makes use in a busy practice not practical.

There are two other serious issues of having your patient data in the cloud. First, just by its very nature, the cloud is more accessible to hackers than your computers behind a router. Even if the cloud security is more robust (and that is not necessarily the case), there is just a much larger number of hackers from around the world who will be trying to hack their way in. There are many fewer hackers who know your computer is sitting behind your router's firewall and thus fewer who will be trying to hack in.

The other issue is that your data and EHR will exist only so long as the vendor decides to support it. Unlike most client/server software, if the EHR vendor goes out of business, you can still start up and use your EHR. If the data is in the cloud that is not the case. For example, in June 2002, GE sent a letter to physician's using their web-based Encounter EHR giving them three months notice that the product would be shut down (read the article here). Users had to scramble to get their data and to find another system, and many users from that time (who now use Amazing Charts) have told me they would never use a cloud based system after that experience.

In my office, I use a program of Doctors.com for scheduling, billing, and e-prescribing. I’m currently negotiating to add an EMR from them. I need guidance on how to choose the rite EMR?-Isak Isakov

If your practice management vendor has an EHR, it’s certainly worth trying theirs if you can without risk, but usually they don't have enough practices to have been included in User Satisfaction studies, so you don't have the provider-years of experience to know if their software works well. Unfortunately, as many EHR vendors tend to do, practice management compnaies see doctors as basically having a target painted on their back, and they say, “Hey, here’s a great way to make some more money,” and they price their EHR at some ridiculous level. So my advice is, it if it free to try and affordable to buy, and already works with your other systems, try it.

When calculating the 75% of Medicare we will receive, will it be based on 2009, 2010, or reevaluated every year? -Dr. Miro

The details of the HITECH stimulus act are not clear. For example, nobody - even five different representatives of the ONC whose task is to oversee and inform physicians - had no clue at the recent HIMSS meeting. My understanding is that monies will be based on the prior year collections (allowables). So, my 2011 payment will be based on 2010, and actually, 2010’s a little different; that’s going to be based on some three month usage period that has yet to be finalized. But, in general, my understanding is that it will be based on the prior 12 months.