Tuesday, December 26, 2006

Money alone won't solve the EHR problem

The amednews recently published an article detailing the saga of a practice that had a failed EHR implementation. The article notes that something like 1 out of 3 EHR implementations ends up in failure, which the article defines as a de-install. If you include the EHR implementations that are permanently stuck -- meaning that the practice implements basic scheduling and billing, but nothing else -- that could mean that 1 out of every 2 EHR implementations are effectively failures.

I don't want to get into whether the EHR system or vendor itself contributed to the failure described in the article; both of the vendors mentioned in the article are supported by MAeHC (the practice left NextGen and is now buying eClinicalWorks) . To me, the most important point raised in the article is that lack of money is not the only issue hampering greater EHR penetration -- it's not even clear that it's the most important obstacle.

Factors that contributed to the failure cited in the article are:
  • Insufficient upfront attention to workflow or process changes required to maximize the EHR's potential
  • Inadequate project management experience and resoures at the practice-level
  • Inexperience with contracts -- writing, negotiating, and managing

This confirms for me that EHR investments are probably not worth it (particularly for small practices) unless they're done under the umbrella of an effectively-managed, community-based program (whether driven by a hospital, IPA, PHO, or RHIO/HIE).

Community-based because there's scale in project management, vendor selection, and contract management, and because patients and physicians will get much more value from EHRs that are coordinated with their medical trading partners (other physicians, hospitals, diagnostic centers in their communities).

Effectively-managed because too many of these programs give scant attention to the project and change management piece of the implementation -- they're usually driven by whiz-bang technology plans (with the requisite clouds and lightning bolts) laid out by IT specialists, and assume that templates and worksheets handed to the practice by EHR vendors and others will take care of the rest. In most cases, they can't and they won't.

I wouldn't recommend that the government or anyone else dump money into EHR programs unless they're managed under a community-focused program umbrella, laying out clear goals and timelines, coordinated interoperability with key trading partners, funding keyed to execution and adoption milestones, and implementation approaches that force behavior change, and maximize and monitor success.

Programs that fund EHRs on a "retail" model -- meaning that they just make money available to physician practices through grants or tax breaks or other practice-focused incentives -- are destined for high rates of failure and could very well cause more harm than good.


Manick said...


As one who has implemented EHR solutions at various small physician sites, I endorse your view that this perhaps is the tipping point. However, should the new Administration provide just tax breaks and incentives to physicians, it will not necessarily result in a transformed world.

Monetary resources are a crucial factor, but more critical to the success is the attention that needs to be paid to the workflow, the cash flow and data conversion at the implementation site.

All practices have people who have been working with a workflow that has been in existence for a while. Changing that workflow could result in their failure to perform. Not because they are not capable, but because care has not been taken to blend the new workflow with the existing one.

Every implementation will have setup parameters, be it configuring a file to be readied for an upload to a clearing house or ensuring that the accounting links are maintained. These need to be inventoried and prepared for integration with the new system, thereby ensuring that there is no cash flow disruption to the practice.

Finally, one of the most important aspects of the implementation is the priming of the data on the new system from a paper based or a semi-electronic system. Typically it is the staff at the site, including the physician who are saddled with this task. They are not trained to do data conversion, which by itself is a task left only to experts. There is any number of ways that this task can be effectively done, but it needs to be planned for and taken into cost considerations. Methods range from onsite data entry to offshore data entry. The actual conversion can be done prior to the implementation, during the implementation and as an ongoing task for a period of time until the practice is ready to go paperless.

This is perhaps the best time in the history of healthcare to do it right. At this point, not all EHR software are built on an interoperable data schema. The prime reason is the evolving nature of that standards effort. As long as such vendors will be mandated to either provide upgrades to their software to be in sync with national standards or at the least, provide easy access to their data should a client want to move to another software vendor, the industry as a whole should move forward.

electronic medical records said...

I agree' "Money alone won't solve the EHR problem" for me.. there is no problem with EHR. I think the problem is in the user. Anyway, thanks for sharing.