By Michael Nissenbaum, President & CEO, Aprima Medical Software
Twitter: @AprimaMedEHR
The ambulatory electronic health record (EHR) replacement market continues to thrive as physicians seek to satisfy new quality reporting requirements, improve inefficient workflows and address the need for interoperable systems. When a practice is struggling with its existing EHR, how do providers and administrators know the time is right to cut their losses and seek a replacement? More importantly, what can practices do to avoid repeating past mistakes, instead of selecting and implementing a solution that addresses both today’s needs and those of the future?
An important first step is for the practice to analyze why its existing EHR has failed. Is the system truly “broken” and unable to deliver the functionality it’s supposed to – or does it simply not perform as efficiently as users would like? For example:
Workflows – Physicians often complain that their EHRs are slow – or simply don’t work. In reality, the problem could be that a particular EHR is not designed to adapt to a provider’s specific workflow because it was designed to capture data, not help a physician.
The workflow of a primary care provider seeing 30 patients per day is very different than that of a specialist treating fewer, more complicated patients, or a practice that sees a high number of patients and also performs procedures. The EHR may include all the functionality the physician needs to thoroughly document a patient visit, but not a procedure (or vice versa) and often requires an inefficient number of steps, reducing the amount of patients he or she can see per day without having to put in extra time just to document patient visits.
System updates – A practice may have implemented an EHR that worked great for several years, but now the vendor is failing to keep up with the latest regulatory requirements, or with new technologies that increase efficiencies or enhance revenues. This is the situation that many providers are facing as they scramble to address new quality tracking and reporting requirements under the Medicare Access and CHIP Reauthorization Act (MACRA). Other vendors may be addressing government-mandated changes, but not offering solutions to enable interoperability with other providers, or to facilitate participation in optional revenue-enhancing programs, such as CMS’s Chronic Care Management (CCM) services.
Multiple applications and/or databases – When a practice has one vendor for its practice management needs and another for its EHR, a myriad of unintended and unwanted consequences can result. These range from managing two vendors, to directing the upgrade timing between the vendors to try to avoid breaking things, to having limitations between the business and clinical operations. A “Best of Breed” approach was useful five to 10 years ago but, as regulatory requirements evolve, it is more and more difficult to get easy and accurate reporting when you have disparate systems. Interfaces don’t always address interoperability needs.
Support – No matter how great a system is, a practice is going to struggle if their vendor fails to address system issues in a timely manner. Practices must have consistent and reliable access to knowledgeable support professionals who are able to clearly communicate appropriate instructions and advice.
Before giving up on an existing EHR, the practice should objectively evaluate whether the current problems are with the vendor and the product – or whether providing additional training to the practice would help mitigate the issues. Practices should ask themselves whether or not their expectations are realistic: a response time of a few hours to address a routine issue might be annoying, but perhaps not a sufficient reason to switch vendors. On the other hand, if the support staff consistently takes four days to return a call, a practice may want to consider other options.
Practices should also consider whether or not their physicians and staff are appropriately committed to making the EHR work. In particular, providers need to make sure they’ve made adequate investments in training resources, especially following the implementation of new features or turnover in staff. A practice that fails to invest in its education may find limited success with its next EHR as well and might have accomplished nothing by switching. No matter how technology savvy a provider or practice is, an investment in proper training (and attendance in the training!) makes a huge impact on the utilization early on as well as long term.
Starting over
If, after a thoughtful evaluation, physicians and staff decide it’s time for a new EHR, all stakeholders must commit to a business-like evaluation process that takes into account multiple factors and avoids repeating mistakes that might have been made selecting and implementing the previous EHR. Practices should identify in advance what features and functions are critical and not assume that every EHR has the same capabilities as the old system. Practices should also ask for customer references as well as evaluate company strength and third-party validations. To minimize confusion between the various options, everyone involved in the selection process should maintain a running record of their observations and impressions of the different solutions.
Some of the key evaluation categories to consider include:
Features and functions – No two practices have identical requirements in terms of features and functions. However, providers should be mindful of larger industry trends, such as the need for interoperability between systems, the transition to new quality tracking and reporting models, and the opportunities to maximize practice revenues and collections. Interoperability requirements may vary between communities based on what technologies are used by local health systems, individual providers and ACOs. To address value-based care requirements, practices should verify the ability of prospective systems to track and report on quality measures, handle bundled payments as well as analyze and manage populations of patients.
For practices managing patients with chronic conditions, CCM functionality is a must. Practices serving patients with high out-of-pocket costs, large deductibles and/or large co-pays need a solution for managing and collecting patient balances that includes an integrated credit card on file program. Finally, in order to minimize challenges with incompatible technologies, practices should seek solutions with fully integrated practice management and EHR capabilities running on a single database.
The company – The EHR vendor, its customer support and its track record in the industry are arguably more important in EHR selection than the actual product: a sexy, bleeding edge EHR is relatively worthless if it is error prone and without a company behind it to provide ongoing training and support. Look for “high-touch” vendors that are committed to developing strong relationships with their customers across all departments. Weigh the relative benefits of privately-held companies versus public companies, including their ability to nimbly adapt to changing industry requirements, their commitment to healthcare and healthcare IT and their history of delivering timely, relevant product updates.
Be wary of products supported by a minute division of a huge entity that could eliminate the solution with a stroke of a red pen. At the same time, make sure the company has a strong history of introducing updates and enhancements and holds a solid client retention record.
References – Do ask the vendor for client references, but don’t be too concerned if the practices don’t match your exact size/geography. What’s more important than a precise match is the ability to talk to a cross-section of similar practices and seek their opinions on the company, the EHR functionality, the support organization and training. It’s also valuable to get an understanding of how the EHR has impacted the practice’s financial and clinical operations.
Third-party validation – In addition to product demonstrations and talking to customers, investigate third-party validations from recognized industry analyst organizations, such as Frost & Sullivan and KLAS. The views of outside analyst firms can help validate your own research – or raise new questions to ask potential vendors.
Ability to convert data – Although every vendor will tell you they can convert your existing data to their system, this is easier said than done. Does your new vendor have the experience and resources to convert your data from your current EHR to their system? The definition of conversion comes in many flavors – make sure you understand what you are getting!
Unfortunately, sometimes EHRs fail to meet a practice’s long-term needs. If your practice has decided it’s time for a new EHR, make sure your selection process is business-like and thoughtful, considering multiple data points to make the very best decision for today, as well as for the future.