EMR Purchase: Caveat Emptor

Physicians practice evidence-based medicine. They base clinical decisions on evidence gained from scientific research and experience. As patients, this is the source of our confidence in their diagnoses and treatment plans for us. Unfortunately, an alarming number of physicians do not apply evidence-based decision-making to their EMR purchases. This explains the 50–80% EMR failure rate documented in the Milbank Quarterly and cited by the AMA.

Recently, I’ve spoken with several ophthalmology practices that are struggling under the weight of unsuccessful EMR implementations—many of these situations would have been averted by asking the right people the right questions at the right time—before signing the EMR contract. Let me share a few examples of how aggressive due diligence uncovers important facts:

Buyer BewareAn ophthalmology practice purchased an EMR from [Vendor 1] based on its ad stating that nearly 500 ophthalmology practices use a [Vendor 1] product. Had the physicians asked for the names of 10 ophthalmology practices of their size that use this vendor’s EMR, they would have learned—by the lack of response—that most of the 500 practices use the vendor’s practice-management system, not its EMR. Don’t fall prey to deceptive marketing.

Beware of references with vested interests. For example, a physician would never know that the reference for [Vendor 2] has an ownership interest in the vendor’s company. Not surprisingly, the reference physician described the EMR as “excellent.” It was only a subsequent blog comment from another physician in the practice that revealed that, after 3 years, she still schedules 6 fewer patients each day and has hired a skilled technician to assist her, adding $37,500 per year in costs.

Another practice made a visit to [Vendor 3’s] reference site and learned that the physicians in the practice are, in fact, using the EMR. If they had probed further and asked about staffing, however, they would have learned that instead of 8 scribes, this practice now employs 24 scribes to handle the necessary data entry—two for each ophthalmologist (instead of one before the EMR adoption), and one for each optometrist (when the optometrists had never needed any scribes at all before the EMR).

It’s equally important to randomly select physicians to call. Do not limit your conversations to those physicians hand-picked by the vendor—other physicians in the practice will always take calls from colleagues. Ask each physician how many patients he or she sees each day now as opposed to before EMR implementation. Within the same practice that purchased [Vendor 4’s] EMR, physicians using the EMR successfully are those who see only 25 patients per day, while the ones who see 60 patients daily do not use it because of its effect on their productivity.

If you apply the same due diligence and evidence-based decision-making to your EMR search that you do to treating your patients, you will have the information you need to ensure that the EMR you select will be the right EMR for your practice.

EMR References: Cast a Wider Net

Client references and site visits can be a rich source of valuable information when you’re shopping for an EMR—but only if approached critically and after conducting your own due diligence. The graph below illustrates the limitations of relying on vendor-supplied client references to make an informed EMR purchase decision.

Impact of EMR on Physician Productivity

This graph represents the effect of EMR adoption on physician productivity, given the acknowledged 50–80% failure rate of traditional EMRs—specialists being on the higher end of the range. Immediately upon adoption, physicians experience a significant reduction in the number of patients they can see, and over time, they hope to regain their productivity. Some are able to achieve their pre-EMR levels, and a small number see an increase above that level—the latter are the physicians in the orange-shaded section. These are the physicians whom vendors will identify as references and whose practices will be offered for site visits.

Every vendor will have a few good references and can take potential customers to visit a “show site” client, but this is not necessarily representative of the experience of the majority of users—the experience that you can likely expect.

If this graph instead portrayed the results of a clinical trial for a new drug, would a physician prescribe this medication based on the fact that 100 (of the 1,000) patients in the study showed positive effects? Clearly not!

Ask the vendor for—and insist on—at least 10 to 15 references of practices in your specialty and at least a few that are close in size to yours. If a vendor cannot provide this, there is reason to question whether its EMR is right for your practice. Call a physician of your choosing in the reference practice(s)—selecting at random from the group’s website is most likely to yield an objective evaluation. Don’t be fooled by one reference, one hand-picked physician, or one “show site” visit.

EMR Reform: A Plan to Spur Adoption

A free market is the most powerful economic force on earth. According to Adam Smith’s The Wealth of Nations, this is because free markets let people make informed purchase decisions based on how products further their own interests. If left to operate without interference, a truly free market rewards products that consumers deem superior, and puts companies with inferior products out of business.

However, informed purchase decisions can be made only when unbiased information is available. Currently, in the EMR market, such information about the myriad of product offerings is largely absent, and purchasers must rely on unauthenticated vendor claims. It’s no wonder that physicians are reluctant to purchase these expensive systems—the risk of a financial disaster looms over their heads.

The barriers to EMR adoption are not problems that government incentives can even begin to remedy. What is needed to truly drive adoption is major healthcare IT reform. Transparency and full disclosure must be introduced in order for market forces to work and for widespread adoption to occur. Just imagine the effect of the following EMR reform proposal:

1. Increase the EMR success rate (and reduce the lamentable failure rate) by increasing product quality and usability through competitive benchmarking.

Physicians should have access to “click” comparisons that measure the efficiency of each EMR in conducting common office workflows—finding a chart, reviewing chart information, sending a message, creating a problem list, creating a prescription, signing off on a lab, or ordering a test. These comparisons would create a race to efficiency as vendors are forced to think about physicians’ workflow and productivity, and would ultimately create more usable, superior products. After all, which vendor would want to be known as the most point-and-click-heavy vendor in the marketplace?

2. Provide transparency by issuing audited vendor report cards.

A report card would measure each vendor’s previous three years of sales and their success/de-install rate by specialty. In the auto industry, the information available through crash-test results and the J.D. Power and Associates consumer-satisfaction reports give manufacturers the motivation to build cars that meet consumers’ needs and preferences. EMR purchasers should have similar quality data enabling them to make successful choices as well. KLAS has laid the important groundwork with their customer-survey-based comparative EMR data, but additional data from objective tests and non-vendor-selected customers would round out the picture.

3. Take the systemic risk out of purchasing an EMR by allowing providers to return EMR licenses if they do not perform as promised—in other words, an EMR Lemon Law.

A return policy would profoundly and positively impact adoption rates since physicians would be less likely to fear being victimized by false sales pitches, and vendors would be more likely to ensure that implementations went smoothly. It would also ensure that products not appropriate for a particular specialty would not be sold to those physicians.

These simple healthcare IT reforms will level the playing field and restore the sorely needed balance between vendors and physicians. The result will be faster, more confident purchase decisions and increased long-term adoption.