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Despite widespread unhappiness, surprisingly few practices say they plan to change their EHR system. Here’s why.
Better the devil you know than the devil you don’t.
That’s the attitude of many physicians when they think about replacing their electronic health record (EHR) system, and it may explain a seeming contradiction in the results of Medical Economics’ 2016 EHR Report Card: while 60% of ambulatory EHR system users either dislike their system or are neutral about it, and nearly half say they wouldn’t recommend it to a colleague, only 15% of respondents say they’re considering switching to another system in the next year.
The reluctance to change EHRs is well-founded, according to those who have done it. Much like going digital for the first time, moving to a new EHR system is almost always time-consuming and disruptive to office workflow. It also involves many of the same costs, in terms of lost productivity and the time required for staff training on the new system.
But switching EHRs includes an additional challenge, and expense: that of transferring patient data from the old system to the new one.
Plus, given the shortcomings of virtually all EHRs, practices face the distinct possibility of ending up no happier or more productive with their new system than they were with the previous one-especially if they don’t do their homework.
“Switching to a new system is a big investment, and you’re impacting practice viability if you’re laying out hundreds of thousands of dollars every few years for a new system,” says Titus Schleyer, DMD, PhD, director of the Center for Biomedical Informatics at the Regenstrief Institute in Indianapolis, Indiana. “So you need to be very careful and prepare for your switch well.”
The number of practices looking to change EHRs is likely to grow in the coming years, for a variety of reasons. EHR use among primary care doctors began increasing at a rapid rate in 2011 when Meaningful Use funds first became available.
Now, some of those systems are becoming outdated or are no longer being supported by their vendor, says Pat Wise, MS, FHIMSS, vice president of information systems for the Healthcare Information Management Systems Society (HIMSS). In addition, Wise notes, the trend of independent practices becoming part of healthcare systems means many of those practices are having to change to the EHR used by the practice’s new owner.
Finally, for practices to be eligible for bonuses under Medicare’s reimbursement programs taking effect next year, they will need some types of technology-such as patient portals-that many older systems simply don’t have.
For whatever reason they decide to switch EHRs, the biggest challenge practices face is transferring patient data from the old system to the new.
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Daniel Goodman, MD, a solo internist in the Atlanta, Georgia suburb of Dunwoody speaks for many when he calls the process “a nightmare.”
Goodman acquired his first EHR when he joined the Emory Health Network in 2012. Three years later, Emory said it would no longer support many of the systems used by its affiliated practices, including Goodman’s, causing him to switch to a system that
Emory would support.
While some of his patient data transferred seamlessly, Goodman encountered numerous problems for which no one seemed to have an explanation, such as patients’ names being duplicated or last and first names being reversed. Eventually, much of the data had to be re-entered manually into his new system. “The whole process was expensive, frustrating and incredibly time-consuming,” he says.
In addition, he says, his previous vendor would grant him access to his patient data only if he continued his subscription. He wound up paying $3,500 to obtain some of the data, such as consult notes and patient progress. But that data did not integrate well into the new system. So now when he sees patients who pre-date the switch he has to toggle frequently among screens and folders to get a complete picture of the patient’s status.
Goodman estimates his practice’s switch cost between $10,000 and $12,000 (not counting the cost of getting his data from the previous vendor) and “Lord knows how much in lost productivity. For the first week we saw nobody, and the next week at most 50% of our usual workload.”
Goodman’s experience in attempting to transfer data is common, according to Derek Kosiorek, CPEHR, CPHIT, a principal consultant with the Medical Group Management Association based in Minneapolis, Minnesota. The problem goes back to the absence of standardization in the design of EHR databases. As a result, “each vendor does it on their own, which makes it very difficult to transfer data from one to the other,” Kosiorek says.
The situation is starting to improve, he adds, thanks to developments such as continuity of care documentation [CCD], but “we’re still a long way away from getting true data standardization.”
(CCD is a standard for the electronic exchange of documents containing summary information about a patient’s present and past health status. Documents exchanged using CCD can be read using most EHRs and other applications such as web browsers.)
But even with the development of CCDs and other types of data standardization, most of the documentation physicians put into EHRs remains in the form of unstructured prose, notes Elizabeth Corley, MD, an executive committee member of the Electronic Health Record Association (EHRA) and chief medical officer at NextGen, an EHR vendor. “And physicians don’t want their notes to sound computer generated, so they would be resistant to having all their documentation completely structured and codified,” she adds.
The key question practices need to consider, Corley says, is how much of their data from their old EHR they want to appear in structured fields on their new system, because the required data mapping adds to the cost of switching.
“Your knee jerk thought when you’re moving from one system to another is ‘of course I want the entire record available in structured fields the way I had it before,’” she says. “But there’s a lot of expense involved with that degree of data mapping.” Moreover, much of the routine information about a patient, such as medication lists, allergies, and immunizations, can be transferred in a CCD.
The data transfer challenge is complicated by the differing attitudes vendors take towards customers who want to switch, says Schleyer. “It ranges all the way from the vendors who say, ‘You own your data, we’ll make it available to you in a usable form,’ to ‘Switching to a new system is going to cost you ‘x’ thousands of dollars and we have to be the ones who do it.’”
(The “EHR Developer Code of Conduct” states, “We will be transparent, to the greatest reasonable extent, with clients regarding pricing and costs to our clients related to interoperability products and services that we offer. We will also provide information on other potential products and services provided by third parties necessary for interoperability with our EHR.”)
Practices that use their EHRs for financial tasks such as billing and revenue cycle management face an additional challenge in moving that data, says Robert Rowley, MD, a healthcare information technology consultant in Heyward, California.
“There’s basically no standardization on the financial side like you get with CCDs,” he says. Basic information such as demographic data and insurance coverage usually will transfer, but little else. Consequently, “all activities generated after the go-live date get adjudicated in the new system, and the stuff that comes in for service before go-live gets adjudicated in the old system.” Until the transition is complete, a practice will need to continue to run the old system alongside the new, Rowley says.
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Concern over data migration also is a major reason why Brett Scotch, DO, hasn’t changed his EHR system. A solo ear, nose and throat practitioner outside of Tampa, Florida, Scotch purchased his EHR eight years ago. He would like a system that better integrates the clinical and revenue cycle management sides of his practice but says, “the biggest thing holding me back is the costs of bringing in extra help to migrate the patient records to a new system.”
Those personnel expenses, he notes, would be in addition to the cost of the new EHR itself, the implementation and training costs, “and just the general disruption of the practice that comes with doing a migration and training your staff to use [the new system].”
The costs and frustrations of installing a new EHR sometimes can fuse into a morale-destroying malaise among providers and staff, says David Zetter, PHR, CHCC, principal of Zetter HealthCare in Mechanicsburg, Pennsylvania, who has shepherded numerous practices through the EHR transition process.
“The doctor’s thinking, ‘this is costing me money to buy a new system and my staff isn’t as productive, and I’m ticked off because nobody knows what they’re doing.’” Zetter says. “That’s how it goes for most practices because they’re either owned by a health system and this is being forced down their throat, or it’s a ‘mom and pop’ practice and nobody has put a [transition] plan together.”
For Good Samaritan Health Center of Cobb, a five-provider, federally qualified health clinic in Marietta, Georgia, the motivation for switching its EHR is the outdated technology used in its current system. Among other problems, the system does not code for ICD-10, and the vendor would have charged $25,000 for the necessary upgrade. “By the time you’ve put $25,000 into this system, you’re halfway to getting a new product,” says Allan Purdie, MD, Good Samaritan’s medical director.
Good Samaritan began searching for a new EHR in January. The experience, which he likens to purchasing a used car, has left Purdie feeling cynical and discouraged. “It seems like the whole game is just a racket,” he says.
So what can a practice do to ensure it will be happier or more productive with a new system than it was with the old? The first step, experts say, is to acknowledge that you’re unlikely to be completely satisfied with any of the products available now. “There is no EHR where large numbers of people are saying, ‘this is so much better than everything else out there,’” says the Regenstrief Institute’s Schleyer.
Nevertheless, practices can take some actions both to ease the pain of transitioning to a new system and be better off afterwards, say consultants and those who have gone through the process. Perhaps not surprisingly, their main suggestion is similar to the advice given to practices acquiring their first EHR: do your homework.
“I would recommend a doctor spend some time in a clinical environment to see the amount of work required to negotiate the system,” says Scotch, the ENT specialist. “And they should investigate at least two or three other systems to make sure they’re getting what they think they’re getting and not jumping into a system that’s not optimal for their needs.”
Scotch adds that he settled on what will probably be his practice’s new system by consulting published rankings of EHR systems and by talking with other ENT practitioners.
When it comes to the all-important issue of transferring patient data, Wise says, practices often face a variety of questions for which there may not be clear answers. For example, what are the costs of transferring the data electronically (assuming that doing so is even possible), versus entering it manually into the new system? And how much of the data even needs to migrate? Information that is decades old may no longer be relevant, Wise notes. So the practice will need to decide if there’s a cutoff point beyond which data won’t be transferred.
Schleyer emphasizes the importance of comparing a new system’s capabilities with those of the practice’s current system. “You want to ask, ‘what can my new system do that my old system is doing, what will it not do that my current system is doing, and vice-versa. That can provide a roadmap to how your computer support for your clinical operations will change,” he says.
Schleyer also recommends developing a cohort of “power users” from all parts of the practice, and assigning them to figure out how to mesh the practice’s workflow with the new system. Doing so, he says, sometimes will reveal a gap in the new system’s capabilities.
Zetter has put together a detailed, multi-page list of steps he recommends to his clients, beginning with exploring only those systems that are designed for their specialty. While that may seem obvious, he adds, some doctors will buy an EHR recommended by a colleague, even though it’s not appropriate for their specialty.
It’s also important to query other system users about their experience with it and its vendor. “Every EHR is going to have issues, both in implementation and support,” he notes. “Find out how they [the vendor] handle those issues.”
Finally, says Zetter, make sure that someone from every department in the practice, and all the providers, try out the new system before making a decision. Each clinician has his or her own way of dealing with patients, and an EHR should help-or at least not hinder-that interaction.
“A physician who wants to keep eye contact with the patient all the time is not going to be happy with having to look at a laptop while talking to the patient,” he says. “So you’ve really got to get all their perspectives before making a decision.”