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Thoughts, comments, news, and reflections about healthcare IT from Microsoft's worldwide health senior director Bill Crounse, MD, on how information technology can improve healthcare delivery and services around the world.

Please take care in selecting an EMR for your practice

Please take care in selecting an EMR for your practice

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Bill Crounse 2007 05 As reported by HDM on-line, the Office of the National Coordinator for Health Information Technology has published additional information on a $598 million grant program to fund the creation of about 70 Health Information Technology Regional Extension Centers.  The centers will help hospitals and physicians select, acquire and use electronic health records systems.

No doubt some serious education and hand-holding will be needed as more physicians and hospitals take the plunge into electronic medical record systems and “meaningful use”.  If taking the plunge is anything like what I saw and heard during a visit to my own doctor last week, doing your EMR homework before you buy is an important step if you hope to swim rather than sink.

image  My doctor belongs to a very large, multi-specialty group practice.  Like most large clinic systems in America this group practice, which also operates a hospital, has been using electronic records for some time.  Even though the multi-specialty clinic drives most of organization’s business, they decided to purchase a health information system that is better known for running hospitals than outpatient medical centers.  As long as I’ve known my doctor, he’s been complaining about the EMR system he is forced to use in the clinic.

And it’s not just my doctor who does the complaining.  On my visit last week, the first thing his assistant did while checking me in was to verbally assault the blankity-blank computer system. She clicked furiously on the screen multiple times waiting for the system to respond.  Just entering my vitals seamed to require clicking through endless screens.  It took a ridiculous amount of keyboard work.  “I hate this system”, she said.  “It is always slow, especially when we are busy.  And several times a day, it just goes down”.

She eventually got through all the screens and entered my data,image although I noticed that she took down my chief complaint and medication list on a sheet of paper perhaps to enter that information into the computer later.  My doctor came into the room, asked me a few questions, and did a cursory exam.  Mainly I was there to get some prescriptions renewed.  My doctor also decided to order a few lab tests on me while I was there.  On my last office visit, he had ordered lab work on the computer.  This time he used a sheet paper.  Before I even had a chance to say something about this he blurted out, “I suppose you noticed that I’m back to ordering lab work on paper.  We tied CPOE (computerized physician order entry) but it just took too long!  The clinic docs revolted, so now we are back to doing it the old fashioned way.”

image Of course, I could have predicted all of this.  There are much better solutions on the market for ambulatory patient care than what my doctor is being forced to use .  There are far more intuitive and responsive EMR solutions.  There are also solutions that are more accommodating to clinical workflow and mobile scenarios using Tablet PCs and other wireless devices.  But my doctor’s group practice spent millions of dollars on what they have, and I’m quite certain they won’t be trashing it anytime soon.

So, let this be a warning.  Do your homework.  Select a system for your practice with the research and care you would put into making any large, really important purchase for your home or business.  Don’t delegate this to your staff.  It is your responsibility.  You, your staff and your practice will be greatly impacted by the decisions you make.  So maybe, just maybe……. a visit to one of those government funded “extension centers” would be a good idea before you take the plunge.

Bill Crounse, MD  Senior Director, Worldwide Health   Microsoft

  • An organization which has clinics as well as hospitals has fewer choices if they want one EMR to integrate inpatient and outpatient worlds. We acquired several clinics using a very good outpatient EMR which was different from our current EMR. The physicians in that practice revolted and refused to switch to the system the rest of the organization uses because it is too unwieldy for outpatient use. Is there a single integrated system which works well in both worlds?

  • But somebody's got to take the plunge so that the others can watch us swim...

  • Very pertinent comment and very common observation in a large group/hospital setting. Interestingly, you would most likely see a very different, quite satisfied physician/nurse at a small practice that has implemented an EMR (like ours or Dr. Segal's). This is because too many IT decisions are made by non-clinicians (administrators/managers/tech folks). Implementing an EMR in an active practice is like trying to change tires while driving a vehicle - has anybody tried that?

    In small practices, physicians often have to wear all the hats, so can make better educated decisions. Besides, most practices looking into an EMR nowadays are only concerned about how much subsidy their local hospital will give them and how they earn the proverbial 44K in Medicare bonuses by implementing an EMR - exactly the wrong way to start the process, in my opinion.

    What is truly needed is a small army of physician-champions that is used effectively to guide those docs to make logical choices based on systems that are potentially going to improve not only their financial bottom line but also their clinical effectiveness. These physician-champions should have at least 3 years' experience operating a fully electronic office and must be appropriately compensated for their expertise and time. No technical expert or academic can replace physicians that have operated successfully using an EMR in the trenches of medicine.

    Unfortunately, every time I broach this idea to a hospital administrator, they are very happy to accept my services, but expect me to provide my services for free. Hence my belief that your experiences will continue to occur, precisely because of the nature of incentives being offered.

  • @Sandy, I think there isn't "one system" to rule them all. That is the unattainable holy grail of IT.

    Careful consideration should be made before selecting an EMR, but ultimately the selection comes down to the best offering for the goal in question.

    The wide range of EMR systems out there certainly can be a nightmare for the whole healthcare IT community. Our software (free & open source) aims to bridge the gap between disparate systems across single or multiple organizations, by integrating medical it systems. See Mirth at mirthcorp.com.

  • Thanks everyone for weighing in on the conversation.  I'm thrilled to see so many docs engaged in the discussion.  You all emphasize the point that clinical guidance is crucial in EMR selection and implementation.

    Bill Crounse, MD

  • A very apt post.  I hope many heed the warning.  I'm a solo internist in Massachusetts.  I started my practice with eClinicalworks.  It seemed like a good choice - lots of other docs in the area use it, the price was right (I didn't count on all the "extra" charges once you sign up), the demo looked good...

    Now, three years later, it's clear I made a big mistake.  The system is an expensive boondoggle and I'm looking at thousands of dollars to try to port to a new system.  No one else I've talked to likes eCW - I hear nothing but complaints from everyone who uses it.

    Any doc considering an EMR should read the fine print, and think very carefully about the downsides before investing in an EMR.  You should definitely insist on a "dry run" before you sign anything: i.e. the company should set up a dummy installation for you and you should try entering some patients, searching for info, etc.  Have your staff try it out too.  

    You won't know what the flaws are until you've used it for a while.  The salesman-operated demo is useless - of course it looks good when he's showing you!  He's a salesman!

    If you're not sure about going to an EMR, probably better to stick with paper.  These things are extremely expensive, with a lot of "hidden" costs like IT support, bandwidth, etc.  and few of the products on the market actually do what they claim.

    We need FAR better standards and regulation before these things are released on unsuspecting doctors and nurses.

  • Sage advice, Dr. Schamess.  Moving to an EMR can be especially daunting (and expensive) for solo practitioners like yourself and small group practices too.  The solution you cite has its fans, but like you say, it should always be "buyer beware".  Do your homework.  Take it for a test drive.  Be wary of hidden fees for support and upgrades.  Consider hiring a consultant to help negotiate the best price.  I know one guy who consistently shaves tens of thousands and sometimes hundreds of thousands of dollars off the cost.  If you haven't taken the plunge, look into the "clinical groupware" movement or to nimble companies like US Health Records (www.ushealthrecords.com) or gloStream (www.glostream.com).

    Bill Crounse, MD    

  • (I do not wish to start an EMR war, but rather intend to make a point.)

    Dr. Schamess was not happy with his EMR, but I know a large number of very happy eClinicalWorks users (myself included). We've encountered no hidden "extras" and have found the support to be quick and responsive.

    Name an EMR and I'm sure I can find physicians that love it and those that hate it. That's just the nature of the business right now.

    Most EMRs have their niche - one may be better for small practice, another for enterprise models.

    Some are better than others for particular specialties (I think eClinicalWorks is very good for Family Medicine).

    Having said that, a salesman demo is NOT the same as hands-on demo on a real system (a must when narrowing down choices).

    These days, there's no excuse for buying an EMR without querying actual users on their experience.

    None of these systems are even close to perfect, but some "flaws" are just not worth getting worked up over.

    I agree with Dr. Schamess that there should be no rush to an EMR. The market will surely see changes as standards are refined and enforced.

    We early adopters learn to roll with those changes (some of us actually enjoy it!). But for the masses, I still think the technology is young.

    -Aaron

  • As important as which one you choose is the implementation. Every EMR system is customized to fit the facility at install time. A "test drive" is the best solution. Set up the EMR system with your real patient data in a test environment and try it out. Often it is not the system, but the way it is set up that determines success. If you can adapt the EMR to your process it will work, if you have to adapt your process to the EMR it often won't.

  • Aaron Segal mentions that "Most EMRs have their niche - one may be better for small practice, another for enterprise models. Some are better than others for particular specialties."

    The uncertainty that physicians face when purchasing an EMR is one of the primary reasons for lackluster EMR adoption.  Many physicians purchase EMRs that work well in a setting different from their own (a solo family physician practice is vastly different from a 25 physician orthopaedic group practice).  Compounding matters, physicians have no hard vendor quality data available to them to help them purchase the appropriate EMR and avert a potentially costly mistake.

    To address this exact problem, I proposed EMR reform (http://blog.srssoft.com/?p=526) that would restore the balance between physicians and vendors and spur adoption.

  • As we can see, the same software can be liked or hated based on each individual's experience. Unfortunately there is currently no objective method to determine which software will fit a practice without actually using one. Which means that you have to learn from your own mistakes.

    I am a 7-year EMR user. What I found was that the critically important element is not the software itself, but the people behind it. I also find that that most people believe that going with the giants of the industry like Allscripts or GE is the best way (generally promoted by local hospitals as well). I believe that the opposite is usually true for the small practice.

    I switched from one EMR to another in 2004 because the new product (IMS from Meditab) had the potential to be shaped to the way I wanted to use it but more importantly the company wanted my business and was willing to reshape the product according to my needs. Besides, the previous vendor simply was trying to nickel and dime me and it was the personnel that ticked me off more than the software.

    In the past 5 years we have come up with innumerable modifications that have not only enhanced the product but allowed to enhance my practice effectiveness.  

    Unfortunately, under the current reimbursement system, physicians simply cannot afford to take chances on an EMR system - not knowing whether it will steer them to higher levels or doom their practice. It is really up to the IT industry to come up with a better marketing strategy that allow docs to use their product until they are happy and have a choice to return it if they are unhappy.

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