Q: How many doctors does it take to doom an EMR installation?  A: Only one, even if everyone else wants to change.

OK, maybe that’s too harsh, but it does bring home a key point. When you’re trying to build support for your EMR launch, you’re probably best advised to root out potential naysayers and empower them to the dickens rather than trotting out your cheerleader (whoops, EHR champion) and having them make inspiring speeches.

I was thinking about this the other day at a local professional gathering, when one of the speakers made a remark that stayed with me.  A vendor executive, whose candor impressed the heck out of me, said the following: ”You may not find any champions to drive your EHR installation, but you’ll always get at least one cynic.”

Amen, sister. It’s just human nature. No matter how bright and sparkly your software installation is, you’ll always have someone who just doesn’t like it and roots for it to fail. Unfortunately, if your application is an EMR, that someone may be a physician, who could — depending on their professional and social clout — talk your project into the ground.

Sadly, it’s often the people who know the least about something new that give it the worst rap, and my sense is that EMR projects are no different.

Beware the physician that hangs on the sidelines, slips away early during training sessions and doesn’t ask many questions. You may be more worried about the doctors that complain loudly, and heaven knows you should address their concerns, but sometimes the clinicians who quietly opt out are just as damaging to EHR user morale.

So, at the risk of being a real pain, I invite you to consider this: does your organization face internal dissent from clinicians who haven’t been given the attention they deserve? Are you taking silence for support?  And most importantly, do you have a strategy for making your cynics happy?

I was glancing through my draft posts today and found this article by Neil Versel, now blogging at Meaningful Healthcare IT News, about State Medical Boards considering making EHR user a condition of medical licensor. That’s right. To renew your medical license using an EHR could be part of the clinical competence test.

On face value, it’s a kind of crazy idea to consider. Although, couple that with a post on EMR Thoughts that talks about a Doctor Quiting His Practice Over EHR Use. Makes you think for a second the value of EHR knowledge for a doctor practicing medicine.

Turns out that Massachusetts has already put this requirement in place starting in 2015. Here’s a quote about that doctor that closed his practice thanks to his inability to use the EHR.

Like all Massachusetts doctors, the physician also was required to comply with the state’s Section 305 law. It mandates that physicians demonstrate competency in EHR use by 2015 to maintain licensure.

I must admit that this is a hard pill to swallow for me. Do we really need to make this a requirement? Does making it a requirement add any value? In Massachusetts it says they’re using CME’s to show a person’s EHR proficiency. A really powerful measure of proficiency < end sarcasm font>. Therein lies the problem. How do you measure EHR proficiency?

Although, the doctor leaving the practice, which is an issue in itself, also illustrates why EHR proficiency shouldn’t be a requirement for a medical license. In the not so distant future, it will be hard to practice medicine without EHR proficiency whether the medical boards require EHR knowledge or not.

In a move which startled seasoned financial industry observers, a coalition of Wall Street investment banks announced that they were investing heavily in high-ticket EMRs — even though they don’t deliver any form of healthcare.

Stock prices for Goldman Sachs (GS), Credit Suisse (CS) and Citigroup (C) rose sharply on the announcement, which comes on the heels of their widely-criticized decision to seek incentives available under the HITECH Act.

“When our industry got bailed out by the federal government, we got hooked,” admits a senior executive with one of the firms. “Besides, we’re already experts at making a huge profit on complicated systems. Compared with managing credit-default swaps, EMR adoption is a piece of cake.”

In an echo of the activity preceding 2008′s market meltdown, bank executives said that they planned to issue “collateralized patient care obligation” bonds, essentially picking up the Meaningful Use risks assumed by hospitals and clinics currently using EMR technology.

The bonds could generate billions in incentive payments for the investment banks, which have suffered as emerging market currencies struggle, equities face downward pressure from a still-troubled U.S. economy and countless mortgages remain near foreclosure.

“Do we know whether patients are getting safe care?  No. But does it matter? Only if hospitals and doctors all default on their EMRs,” said Goldman Sachs chairman Lloyd Blankfein. “And that couldn’t possibly happen. Really. We’re serious this time. ”

Blankfein believes healthcare is a no-lose proposition for firms like his. “If the EMR rollouts don’t work out longer term, and the bonds go south, it’s no big deal — we’ll already have our money,” he said. “More importantly, who will push through an Epic installation for a 200-bed hospital in the middle of Kansas if we don’t do this?  We’re doing God’s work.”

For years, public health officials and health leaders have been sounding the praises of EMRs, arguing that patients would enjoy safer, more effective care once providers went digital.

For a while, it was a tough sell, with surveys repeatedly suggesting that patients were suspicious that their data would be compromised or shared without their permission. Others seemingly just weren’t impressed with the concept.

Of late, however, it seems that the public has caught up, and may be well ahead of the provider community in its enthusiasm for digitizing medical records.  According to a new survey by GfK Roper, 78 percent of patients believe an EMR will allow doctors to give them better care whose doctors use EMRs believe that it helps the doctor provide better care.

According to Practice Fusion, an EMR vendor which backed the survey, patients are eager to get e-mailed appointment reminders, have their prescriptions sent electronically and view appointments online.

But wait a minute. Even if backing by a vendor hasn’t tilted the results, this kind of study doesn’t necessarily mean that patients really want an EMR as such.

My guess is that the folks surveyed by Roper have caught wind of a few cool things that more advanced medical practices and hospitals are doing (such as telemedicine, making test results accessible online and appointment scheduling) and they want in. Everybody likes convenience, no?

Somehow, I doubt they’re thinking about care coordination, sharing of medical records from one institution to another across an HIE, integrating data from various departments within a facility, creating data warehouses to do quality studies and so on.  They’re just starting to get a feel for the bells and whistles, some of which don’t even require an EMR to execute.

No, the truth is that it most Americans will never understand the clinical problems EMRs are designed to solve, as most will never delve into issues like risk analysis and patient safety management.  So their interest will inevitably flag.

But for now, we’ve got their attention. This is a moment — the EMR’s “15 minutes of fame” — in which the buzz is so intense that even consumers are getting excited.

Providers, now is the time:  Reach out and educate consumers on the value of your EMR investment while they’re still interested.  This moment may not come again.

UPDATE: As you’ll see above, Practice Fusion was kind enough to correct my understanding of a key part of of the study.  The idea that patients whose doctors already have EMRs in place are happy about it is different, of course, than saying that consumers generally want doctors to hurry up and adopt one. That being said, I’d still argue that even these patients are at a gee-whiz stage, and that their enthusiasm won’t last long. What do you think?

If I were running a medical practice — and knew I had to roll an EMR soon — I’d be banging my head against a wall.  While there’s plenty of talk about the reasons for EMR adoption (in some cases, 44,000 reasons) what consistent, reliable, accessible sources of information can physicians find on the subject?

You may think, “doubtless there’s plenty of colleagues to talk with, not to mention news stories and how-to sites out there, for physicians wanting an EMR,”  but it’s really not that simple:

*  Sure, physicians trust their peers, but with so few having gone whole-heartedly into the EMR game, there’s not a ton of peer support available — and that holds adoption down. You gotta love the whole chicken-and-egg dilemma here.

* Medical practice journals toss off the occasional article on the subject, but they’re often just highlighting a study on how many their peers are also looking into buying in (big help!)

*  Consultants of unknown bias pump out advice on how to choose an EMR, but it’s scattershot and often goes too technical or gets long-winded

*  Bibles of the medical news industry may pop out a case study or two on EMR adoption, but they’re usually focused on big players like the Cleveland Clinic, not the two- to five-physician practices that really need feedback.

* Sure, there’s the Regional Extension Centers, but I’m having trouble visualizing how an already intimidated doctor would bring him or herself to spend enough time with them to benefit.

* Of course, vendors are happy to tell nice stories about EMR use by small practices, but everyone takes those with a grain of salt, with good reason.

In other words, for a problem of such importance, there’s far too little appropriate guidance out there.

In truth, some medical societies probably are reaching out, not to mention hospitals, health plans and government, with reasonably useful suggestions.  But it’s still like a violent info thunderstorm out there.  Unless physicians find an ongoing source of reassuring guidance, which seems relatively unbiased and thorough, many are likely to hang back.

It comes down to this.  Incentives or no, no small business in or outside of medicine makes such a significant purchase without feeling comfortable — and if I was a low-tech doctor, I wouldn’t know how to get there. This can’t be good.

As we noted in a previous post, the latest group of EMR buyers have gotten savvy about support.  As a new study suggests, more than ever, providers are choosing vendors who offer a great deal of handholding.  And that’s probably a good idea, according to Michael Patmas of the American College of Healthcare Executives.  Below,  here’s some of his thoughts on EMR and CPOE project failures.

I have had the unfortunate experience of being in two organizations that had EMR and / or CPOE implementation failures as well as one organization that was successful. A key learning for me was the need to adequately fund training and support. Too often, implementation plans are driven by the vendor who tend to under emphasize the training needs. Simply providing a few hours of hands on training for the physicians is not enough. The real training begins after one flips the switch and providers have to actually work with the system in real time during clinical encounters. That’s when having trainers available to sit with and coach the providers is essential. In every implementation failure I have seen, the organizations under-invested in training and ongoing support.

Sadly, though, many providers seem to cross  their fingers and hope a little training will somehow diffuse automatically into the organization.  This is a dangerously irresponsible stance, but it’s all too common.

In fact,  at three separate community hospitals, I’ve personally witnessed doctors and nurses huddled together over an EMR workstation trying to teach each other how to use the system.  If it made me squirm — under these circumstances, serious  errors like misdocumenting drug allergies are all but inevitable — hospital leaders should be terrified, shouldn’t they?

Just stumbled across a nice list from Physicians EHR listing 10 tips for keeping your EHR implementation within budget. Many of the tips offer smart suggestions on how to plan, including:

* Developing a pre-implementation budgeting worksheet listing project hard and soft costs
* Finding out which practitioners meet vendor requirements to be “licensed users”
* Conducting an inventory of current hardware to see if some items can be used with the new system

I have some serious quibbles with a couple of these points, though.

For one thing, they’re suggesting that management planners prepare for a six to 12 week reduction in productivity after go-live — and suggest that it will begin to bounce back weeks eight to 12.

While I don’t have hard data on this, this sounds bogus. The anecdotes I hear suggest that planners should expect productivity to drop for a much longer period, maybe several months if not more.  (This of course begs the question of whether the rest of the analyses you’ve so carefully made will work, as low productivity can shoot the budget by itself.)

I’d also wonder whether it makes sense to “project EHR-related efficiencies” prior to implementation.  While this is nothing more than common sense for most rollouts, EHR implementations are still something of a black box.

The reality is that the whole phenomenon of widespread EHR use is new, and the data on efficiencies scarce. I’d argue that the time to do that analysis is after testing the implementation with a select group of clinical users for three to six months, not trying to do ahead of time.

Still, I can’t argue with putting an emphasis on projected costs, analyzing software options and preparing for consulting fees.  All told, this list is worth a look if you’re planning your EHR rollout.

Caught an interesting analysis this week from the California HealthCare Foundation, which has been studying EHR deployment within community clinics and health centers since 2006.

In most cases, chart abstraction creates a major bottleneck which can slow the transition to EHR use to a crawl, while cratering caregiver productivity in the process.  But if it’s done thoughtfully, you can avoid some of the chaos, the study suggests.

In its new paper, the foundation shares chart abstraction techiques that used by members of its California Networks for EHR Adoption initiative.

Here’s some strategies CHCF has identified which seem to speed  up the process – and in turn, streamline EHR deployment. (This is just a small sample; I highly recommend you check out the paper itself for detailed case studies and advice.)

Some of the research group’s suggestions:

* Start with a strategy: Decide in advance what information will be entered, when, and by whom — and decide how closely the EHR data should resemble the paper version.  Just as importantly, decide whether any given piece of data is really worth entering at all.

* Don’t abandon paper too quickly: How do you abstract paper chart data?  Usually, you consider scanning charts, migrating data from legacy systems, entering data manually or going for a mix of all of the above.  While each can work, the key is not to drop paper charts too quickly.  To reassure staff, the clinics in CHCF’s initiative typically kept paper on hand all the way through the EHR go-live period — and sometimes for a while afterwards.

*  Fine-tune your abstraction approach: Clinics that did well with the abstraction process had make near-constant adjustments to their process.  For example, one clinic had to move quickly from traditional scanning to a software solution which gave the docs smart headers, after staff wasted countless hours poring over cryptically-named scans. Then, when that wasn’t enough, it had to develop a hierarchical naming system for scans not long after.

Readers, are you struggling with chart abstraction process as you prepare for EHR deployment?  Has staff productivity taken a big  hit?  Perhaps most importantly, how long do you think it will be before the paper-to-electronic- data process stops being an issue?

The CDC recently did a survey of EMR use in doctor’s offices and they reported that EMR use rose to 50.7% in 2010. The 50.7% of physicians estimated to use EMR systems in 2010 was up from 48.3% in 2009, 42% in 2008 and 34.8% in 2007. Well, with that data, I think it’s pretty clear that they have some issues defining EMR use, no?

Here’s a paragraph from the American Medical News article on the study:

The latest CDC information on EMR use, released on Dec. 14, 2010, was based on surveys mailed to 10,301 physicians between April and July 2010. About two-thirds of physicians responded to the survey, according to the CDC. The 50.7% of physicians estimated to use such systems in 2010 was up from 48.3% in 2009, 42% in 2008 and 34.8% in 2007. The 2010 estimate is preliminary, because it relies only on the mailed responses and not answers gathered through follow-up calls. The CDC National Center for Health Statistics counted as an EMR any system that is all or partially electronic and is not used exclusively for billing.

So, from this paragraph let me provide a better conclusion: 50.7% of Physicians use some form of software in their clinic.

As most of you know, I’m not a huge fan of arguing over the definition of words, but to say that over 50% of doctors use EMR is laughable since their definition of EMR is so broad. Here’s the real details from the study on what percentage actually really use an EMR (as most people would define EMR):

According to the survey, 24.9% of office-based physicians had access to a “basic” EMR system, while only 10.1% had a “fully functional” system.

I think their definition of “fully functional” EMR system is probably too stringent. Their definition of “basic” EMR system is probably too simple. So, I’d conclude that actual EMR use is somewhere between 10% and 34.9% or 22.45% if we average the 2 numbers. Close to 25% EMR adoption feels like the right number to me, so I’m glad to see the real data supports that conclusion.

What the 50% number does indicate is that half of physicians are looking at electronic methods to improve their office. I’d project that another 25% are seriously considering the idea of implementing an EMR, but haven’t done anything yet. 75% (using my projections) of doctors interested in EMR and other technology is still a bit far from the 100% number, but considering the past history of healthcare IT I’ll say that’s progress.

The always interesting and passionate Al Borges, MD posted a comment in response to my post from over a year ago about EMR tire kickers and EMR Adoption:

>>> “I think we’re going to see a tremendous increase in EMR purchases at that point in time.”

Why did you believe this back then, John?

Doctors aren’t stupid- most won’t throw themselves at MU’s $44,000.00 only to be left straddled with a loss from year 1 due to the estimated costs of owning an EHR and doing MU for eternity of $40-60,000.00 per year.

Time has shown that the HIT industry has stagnated, with few doctors now buying into the politically driven HITECH Act. I can’t wait until the next CDC biyearly report…

Here’s my response to Al’s comment:

Al,
I still think that statement’s true. There’s going to be a spike in those that purchase EMR software to get the EMR stimulus money. Many were already considering buying it before the stimulus and now a good number of doctors will buy an EMR now that we have the details and timelines for the EMR stimulus.

After this jump in sales, it’s then going to be interesting to watch. The future sales of EMR software are going to be highly dependent on the experience of these initial EMR implementations. If they’re successful and doctors like their EMR and get the EMR stimulus money, then we’ll see more EMR adoption. If they don’t like it or have trouble getting the EMR stimulus money or experience many of the headaches of EMR adoption that we’ve seen before, then I believe it will actually set EMR adoption back long term.

I know which way you lean on that scale. I still think the jury is out, but I am concerned that the later scenario is a distinct possibility.

If the later scenario of an EMR adoption setback occurs, I’m not sure we’ll come out of it until the next generation of “digital natives” finish medical school and achieve prominent enough status in a clinic to push EMR adoption again.

I did misjudge the time it would take to really get the details of the EMR stimulus in place. I thought by February or March of 2010 we’d have known more than we did. Turns out the legislative details took much longer than I expected, but I think we’ll see the EMR adoption spike now that the details are finally in. At least that’s the view I see as far as action and interest in selecting and implementing an EMR.

What do you guys think? How is EMR adoption going and what EMR adoption trends do you see happening in the future?