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.

How to Avoid the Sting of a Bad EMR Choice

The paltry adoption rate, high failure rate, and increasing number of de-installations all indicate that the process typically used to make EMR purchase decisions is seriously flawed. So how does a practice avoid making the wrong choice and buying EMR software that does not meet the needs of its physicians? I believe that they must fundamentally alter the evaluation process.

The typical process relinquishes too much power to the vendors. The practice convenes a committee that conducts a cursory review of (typically) name-brand EMRs, narrows the list down to three or four vendors, and invites the vendors to put on a “Dog and Pony Show.” Each vendor comes with a flashy presentation, shows a structured demo using a “canned” patient with a simple problem, provides several references of happy customers, and predicts a sizeable and rapid ROI. They then offer to introduce the practice to a showcase client. The problem: This process gives the physicians no way of predicting the effect on productivity, or of evaluating usability and comparative efficiency. Most importantly, physicians are left blissfully unaware of the historic failure rate of each of the EMRs they are considering.

The following are some suggestions for a more meaningful evaluation process, one that restores the power to you—the physicians and practices—and yields more realistic and valuable information:

  • Invite (i.e., require) vendors to participate in a side-by-side comparison test, which will allow you to benchmark the number of clicks it takes to accomplish the most common practice workflow tasks. Focus on the 20% of the tasks that make up 80% of a typical physician and office staff workflow—reviewing specific chart information before seeing a patient, signing off on a message, reviewing labs, or generating a prescription, for example. The other fancy features touted by EMRs are irrelevant to productivity. Clicks are time, and time is money, so this analysis will provide a true measure of relative efficiency and opportunity for increased revenue and profit generation.
  • Use real patients with typical clinical presentations, or simulated patients of your design—not the standard patient used in the vendor’s demo. This information will be directly relevant to your physicians and will demonstrate how usable and flexible each EMR is for you.
  • Ask for the names of 20 clients of your practice’s specialty and size who have recently purchased and implemented each vendor’s EMR. This will give a better idea of the vendor’s depth of experience with your type of physicians. Don’t rely on the vendor’s references—do your own networking and research. This is the only way to uncover the not-so-successful implementations in addition to the well-marketed successes.
  • When negotiating contracts, ensure that the physicians are protected on the down side—insist on having the option to be refunded the entire purchase price of the software if physicians do not adopt it. This will demonstrate the vendor‘s confidence (or lack or confidence) in their product and will ensure that you will get the highest level of implementation services and support. You must protect yourself from vendors who are anticipating a crush of orders stemming from the Stimulus Plan and who will send green employees to manage your implementation, thereby reducing your chances of success.

EMR Reform, outlined in a past blog, would dramatically facilitate this process, adding necessary transparency and restoring the balance between physicians and providers.