MGMA Confirms Productivity Loss with Government’s EMR Program

What struck me at last week’s annual meeting of HIMSS (Health Information and Management Systems Society) was the conspicuous absence of conversation about the effect of the ARRA legislation on physician productivity—there was hardly a mention of the subject throughout the conference. Jeffrey Belden, M.D., of the HIMSS Usability Taskforce, did point out that documenting patient exams in an EMR takes 10 times as long as documenting by dictation, but offered no solution to that problem. Admittedly, the audience contained few, if any, physicians. However, once again, it struck me that physician productivity was the elephant in the room—the topic that no one was discussing, even though physicians are the very people upon whom the success of the program is so dependent.

I arrived home to the release of the results of a new MGMA study (conducted last month), which concluded that practices expect that the operational changes required to meet the proposed meaningful use criteria will cause a significant decrease in productivity. Nearly 68% of the respondents anticipate such a decrease, with 31% projecting that the decrease would exceed 10%—and this was likely based on only the impact of Stage 1 meaningful use criteria.

This productivity loss is what I described in last week’s EMR Straight Talk post, where ARRA meaningful use requirements compound the reduction in productivity that is already associated with the “point-and-click” EMRs themselves. Before ARRA, physicians estimated that traditional EMRs reduced their productivity by between 20% and 40%, as documented in testimonials posted on the Government’s FACA blog and included in the Voice of the Physician Petition. Others are speaking out about this issue as well; Paul Roemer reported that his cardiologist puts the productivity loss at 30%, due to the amount of time that he “wastes” performing clerical—i.e., data entry—tasks. (Read his comments in “Healthcare IT, How Good is Your Strategy: A Scathing Rebuke of EHR.”) Added together, this means that physicians face a 40% reduction in productivity at the outset. Imagine what will happen to productivity when the more stringent Stage 2 and 3 meaningful use criteria are implemented!

The conclusion is clear. Physicians should not be considering EHR adoption for the incentive money; they should be looking at what will help them address their business and patient-care needs. The HIMSS keynote address by chairman Barry Chaiken, M.D., charged the EMR industry with “creating healthcare IT solutions that are so compelling, so irresistible, that people just want to use them.” Systems like that already exist—they just don’t interest the government, which appears to be more interested in data collection than EHR adoption.

Government EHR Program: Potentially Harmful Unintended Consequences

I am really intrigued by the latest creation from the Department of Health and Human Services (HHS). Last week, HHS announced a contract to set up a group of experts to identify and attempt to fix any “undesirable” and “potentially harmful unintended consequences” that result from the stimulus legislation’s EHR incentives. According to the announcement, which was posted on the Federal Business Opportunities website: “Historical experience, as well as mounting evidence of unexpected problems, demands that we consider potential downsides.”

My curiosity is piqued! What are the unexpected consequences the government anticipates, and why is HHS so concerned? Awaiting the report from the panel of experts, I started thinking—and it didn’t take me long to create a list of my own.

My top three unintended consequences are the following: (If you’d like to suggest other potential unanticipated consequences—positive or negative—please submit a comment at the bottom of this page.)

  • There will be more EHR failures than successes, particularly among high-performance specialists.
  • “Certification” will stifle innovation.
  • Productivity and physician-focused EHRs will lead the market among high-performance physicians.

More EHR Failures:

After an initial peak in implementations, long-term EHR adoption will slow—particularly among high-performance specialists—and the current failure rate will escalate. Many factors will contribute to this: (1) Some physicians will rush into EHR purchases without conducting proper due diligence. (2) Products that were overly complex and did not work in busy specialists’ practices in the past will surely not succeed now, particularly since these same products must now be used in an even more structured and demanding way. (3) Sorely needed implementation and training will be provided by inexperienced and rushed implementation teams, further reducing the likelihood of success with providers, many of whom are less technologically savvy than the early adopters. (4) Where there was never a convincing economic justification in the past, the addition of data-collection requirements will further lessen the economic feasibility of traditional, point-and-click EHRs. (5) Physicians will try to transfer data entry tasks to scribes and other lower-cost employees (assuming that the regulations allow CPOE to be done by other than the ordering provider), but this strategy will not make economic sense, either, since the additional costs will outweigh the government incentives. The result? The high failure rate will leave physicians “holding the bag” after investing large sums of money, failing to earn the anticipated incentives, and owning a system that doesn’t meet their needs.

“Certification” will stifle innovation:

Innovation will suffer, as it did in the past when many EHR vendors devoted all their development resources to complying with the long list of CCHIT-certification requirements. Forcing all vendors seeking certification to meet the same criteria will surely sap the drive for innovation. As vendors burn through precious development resources to meet evolving government standards instead of improving their core product, they will fail to respond to the interests of their customers, i.e., the physicians. Sales and marketing will drive physicians’ choices, rather than the EHR products themselves. Large companies, which have the largest sales organizations and marketing budgets, will be successful in the short term. Smaller vendors who follow the herd instead of their entrepreneurial and innovative instincts will be driven out of the market.

Productivity and physician-focused EHRs will lead the market:

The good news is that innovation will triumph in the end. Alternative solutions—like the hybrid EMR—will prevail as high-performance physicians find success with products that focus on their needs and enhance their productivity. It will take 4 to 5 years for physicians who have experienced government-program EHR failures to reapproach the market after amortizing their losses. These physicians will seek products that focus on clinical-workflow efficiency and physician productivity. The long-term winners in the EHR market will be those vendors who resist the temptation to chase the “windfall” stemming from the stimulus legislation, and instead focus on improving their products to deliver these benefits.

Please share your thoughts on other possible unintended consequences by submitting a comment below.

RFP: Relevant For Productivity?

Identifying the right EHR for a practice has always been difficult—there are so many choices; there is no objective information about competing products; you have to rely on vendor-identified references; and there is an abundance of misinformation about what is (or is not) required by the government. To sort out this information, consultants and practices often rely on the well-known acronym RFP—Request for Proposal—even though the RFP process is flawed.

The big problem with RFPs is that they emphasize the wrong criteria. They yield information about product features and functionality, but not usability and impact on productivity. It’s like buying a car with a full set of luxury options, only to realize later that it tops out at 40 miles per hour. What you didn’t consider is “usability.” EHR failure is tied directly to the impact on physician productivity, yet not one of the last 10 RFPs I’ve received—each containing 100–200 questions—has even mentioned productivity. In fact, by their very nature, RFPs cannot evaluate the characteristics most critical to successful adoption because there is no way to objectively measure things like productivity, efficiency, and usability in a written format. This is why practices using RFPs still end up as part of the 50% EHR-adoption failure statistics.

RFPs provide detailed information about product features and functionality; however, here’s what you can’t learn from even the most comprehensive RFP:

  • How long it takes a physician to use the features to accomplish routine clinical tasks—for example, write a prescription, review a chart, or send a message.
  • What the net effect on productivity will be—during implementation phase and ongoing.
  • What the likelihood is of receiving government incentives—i.e., your ability to use the EHR as required.
  • How great the failure rate/number of dissatisfied clients is—from de-installations to clients no longer using the software—particularly in your specialty and practice size.
  • What percentage of customers is not using the EHR fully—e.g., still dictating exam notes and transcribing.

To obtain this critical information, practices must take control of the competitive analysis process. Do your own benchmarking of the number of clicks and time required to accomplish a few simple tasks with each of the EHRs under consideration. To estimate the value of the impact on productivity, input the time difference per exam into the productivity calculator. The insights gathered regarding the comparative merits of EHR products will be infinitely more valuable than the information received in response to a 20-page RFP.

Instead of relying solely on an RFP, use a stopwatch to evaluate and compare EHRs. If you would like a stopwatch, just e-mail your name and address to stopwatch@srssoft.com and I will send you a complimentary one.

The Elephant in the Room

The search for the perfect EMR involves an extensive list of criteria related to features and functions, cost, hardware requirements, certification, references—and since February, the potential to obtain government incentive money. Search committees are assembled, consultants are engaged, RFPs are solicited, presentations are made, and references are checked. But there is a big elephant in the room that everyone is ignoring—physician productivity.

The effects of productivity are enormous. Changes in physician productivity dramatically and directly impact the practice’s bottom line. You can calculate the cost for yourself using the Productivity Calculator discussed in a prior blog. Physician productivity has broader societal impacts as well. Decreased productivity means fewer patients seen in the face of higher demand for care by aging baby boomers and the massive numbers of newly insured patients under proposed health care reform legislation. This is further compounded by the shortage of physicians.

Why is no one looking at productivity? Why aren’t physicians and medical societies insisting that productivity information be made available and be the focus of the EMR selection process? Why do RFPs—typically written by consultants—contain no questions about productivity? CCHIT certification has never included any evaluation of productivity, and neither does the government’s “meaningful use” matrix. Even at the recent MGMA Annual Conference there was no mention of productivity in a session on implementing EHR technology. A reasonable explanation might be that objective information about comparative productivity is not available. However, this problem could be remedied by EMR Reform—but that proposal is meeting with resistance within the industry.

Some of the answers to the questions above are less surprising than others. I believe that vendors are afraid of what comparative benchmarking would reveal about their products’ performance under close scrutiny of productivity. It is not in the vendors’ interest to yield control of the EMR evaluation process—not when scripted presentations permit skirting the productivity issue entirely. Consultants don’t feel confident that they have the tools to effectively compare productivity, particularly if vendors are not supportive of productivity measurement. What confounds me, however, is the lack of concern being expressed by physicians and their representative professional groups. I can only assume that it is due to the fear-based marketing efforts to which they are being subjected. Physicians are being told that they must buy an EMR because the government requires it and because everyone else will buy one—neither of which is true. What physicians should be fearful of is the loss of productivity that they will suffer if they do not consider productivity as a primary factor in the EMR selection process.

At next week’s HIT Policy Committee meeting, defining “meaningful use” for specialists will be a primary agenda item. We will advocate that meeting the government’s goals for widespread EHR adoption requires that physician productivity—the elephant in the room—be addressed.

As Promised, Your Voice Was Heard

At Friday’s HIT Policy Committee meeting, SRSsoft Vice President of Government Affairs, Lynn Scheps, presented the Voice of the Physician petition to David Blumenthal, M.D., National Coordinator for Health Information Technology, and to each member of the committee (see pictures below). Lynn went to Washington, D.C., to make sure that the decision-makers heard your voice loudly and clearly—she urged them to read the petition and to heed the comments submitted by SRS clients and the comments written by non-SRS users. Taking the microphone, Lynn addressed the group with the following statement:

Presentation of the Voice of the Physician to the HIT Policy Committee
August 14, 2009

I have attended your past meetings via webcast, but I felt it was important to be here today to personally deliver this book, which you received this morning. The Voice of the Physician is a petition asking you to listen to private-practice physicians, on whose participation the success of the program depends. These are the physicians who will have to “achieve” what their EHR only has to be “capable of achieving.” They implore you to consider the daily realities of medical practice as you move forward.

The fact that a relatively small company like ours would receive such a response in just a few weeks, with minimal outreach efforts, is an indication of the deep level of concern pervading the physician community. Two things are clear: Physicians feel that their voice is not being heard and they perceive the government’s expectations as overly burdensome from a practical perspective.

The signers of this petition are not all SRS clients. Other providers reached out to us and asked that we stand up for them as well. SRS users or not, they are passionate about EHRs, and they speak from positive and negative experience with a variety of EHR products. Three fundamental themes dominated:

  • Physicians will not adopt technology that compromises their productivity,
  • They will not become data entry clerks, and
  • They will not jeopardize the physician-patient relationship.

No financial incentives or penalties will persuade these physicians to take actions they deem detrimental, or not valuable, to their practices.

One hundred and fifty of the signers of the petition are so concerned that they took the time to compose their own supplemental comments for you to consider. I hope that you will take the time to read through even a portion of them—their tone, intensity, and content provide valuable insight into what will be necessary to successfully encourage widespread EHR adoption.

Lynn Scheps, VP Government Affairs, SRS

SRS Vice President of Government Affairs, Lynn Scheps, distributes petition

Petition Distribution

The petition alongside the meeting agenda

The Silent Majority Is Being Heard – Let’s Be Louder

The tide appears to be changing as the voices of the silent majority are finally being recognized in Washington. I have been repeatedly and emphatically expressing my concern that the needs of physicians—particularly high-performance physicians—are being ignored as the government attempts to encourage EHR adoption.

  • Last week, Gayle Harrell, an HIT Policy Committee member, made many of the same points that I have been making, as the Committee reviewed the initial set of recommendations on “Meaningful Use” and considered EHR certification. (Read the highlights in the post below, Finally, A Voice of Reason!)
  • In recent months, many of you have been speaking out on Straight Talk and other blogs. To the question asked in last week’s poll—is the government putting too much of a burden on physicians?—a resounding 90% of respondents answered “Yes.”
  • Physicians are voting with their pocketbooks, continuing to base their EMR purchase decisions on the best way to help their practices deliver the highest quality care in the most efficient manner, rather than on the promise of potential government incentives.
  • Even CCHIT (Commission for Certification of Healthcare Information Technology) has acknowledged these and other voices of reason. Just recently, CCHIT backed down on its all-or-nothing stance and proposed broadening its certification program to include alternative paths to EMR certification.

Comments like those of Dr. Boss (below) attest to the value of alternative, innovative solutions, such as the hybrid EMR, and to the importance of including them in the government’s plans for widespread EHR adoption:

“The best EHR system out there without a shadow of a doubt is SRS, even though it is not yet CCHIT certified. It is cost effective, user friendly to those of us who are not computer ‘geeks,’ and the company is extremely responsive to any needs of ours that arise. If the entire country was on SRS, a lot of our current difficulties would go away.”

Richard S. Boss, M.D.
Pine Medical Group, Fremont, MI
20-Physician Multi-Specialty Group

We will be sending you an e-mail tomorrow, giving you the opportunity to join us and have your voice heard before the final decisions are made in Washington.