EHR divorce: What's driving dissatisfaction?

One in five physicians may be filing for divorce from their electronic health record (EHR) system. While it’s a sobering statistic that is being validated by multiple market surveys – from Black Book to AmericanEHR Partners [a group developed by Cientis Technologies and the American College of Physicians (ACP)], it signals a new era in the adoption and acceptance of health information technology.

“This is an odd point in history,” explains MGMA Healthcare Consulting Group’s Derek Kosiorek, “where we have asked physicians to take processes they have done their entire professional career and change them. We are taking the paper chart and every piece of information in that paper chart and we are shuffling it up like a deck of cards and putting it on a computer screen in different places.”

How could that not influence attitudes, especially when you factor in an increasing economic pressure to build new efficiencies, adhere to a throng of government compliance mandates, nurture and coach your staff, and maintain a daunting pace to see more patients in order stay ahead of tighter public and private reimbursements?

Dissatisfaction is as diverse as the user’s expectations in the first place, experts say, and to truly understand the reasons for it might be based on a litany of factors like computer competency, practice size, organizational structure, clinical and business processes, hardware, speed of system, access points within the practice and attitudes about technology in the first place. Despite the U.S. government dishing out $3.3 billion to MDs and DOs for its EHR adoption incentive program, satisfaction could likely be translated into one simple premise: help users find information when they need it.

 “The bottom line is a physician needs this information available to help them make important healthcare decisions,” says Kosiorek. “And if they have to hunt to find the information, it is an extremely frustrating proposition.”

This angst has been captured in AmericanEHR’s survey from 2010 to 2012 showing very dissatisfied users increased 10% for the same time period. The percentage of clinicians who would not recommednd their EHR to a colleague increased from 24% in 2010 to 39% in 2012, reports Alan Brookstone, MD, chairman of Cientis and co-founder of AmericanEHR Partners.

Some other results from the survey include:

34% were very dissatisfied with the ability of their EHR to decrease workload

32% of respondents had not “returned to normal productivity” compared to 20%  in 2010.

37% in 2012 were dissatisfied with the EHR’s ease of use

So, why the apparent disconnect between vendor and physician?

The bell curve

Jacob Reider, MD, a family physician and director of the Office of the Chief Medical Officer of the Office of the National Coordinator (ONC) for Health Information Technology in Washington, says it is a multifactorial issue that is influenced by the 2012 class of EHR adopters.

In fact, consider that a traditional adoption curve is made up of the early adopters, fast followers, early majority, etc. In the physician market, health information technology adoption is at the 50% mark. Early adopters are far more tolerant of slightly challenging technical solutions,” Reider says. “When they succeed, typically the enthusiasm generated may leave false impressions about the capabilities of the technology. When the next group that adopts the technology are not necessarily as skilled or proficient and have very high expectations. Well, they become dissatisfied.

The market, Reider says, realizes that “when you plug these things in, they are not purring like a BMW right away.”

Is it time for counseling?

EHR usability is solely based on the experience of the user. Some of the perceptions about a system could be based on cost, usability, design, functionality and the skill of the operator.

So, if you find yourself wanting to split up with your EHR system, take time to identify the cause of your frustration. Is it the speed of the network? How long is it taking to access information? Is your system able to interface with laboratories? How are the claims processing features? Is the dashboard simply not intuitive? Are there too many repetitive functions?

 Also, clearly differentiate your evaluation of an EHR based on its competencies “to deliver on the business needs of the practice compared to the EHR’s ability to assist in improvements in quality of care,” Brookstone says.

Remember that most physicians’ practices have limited capacity. “Adding technology to the practice is also adding new responsibilities.

“Normally, in a product development cycle, you would expect to see the technology and software, and maybe the hardware, adapting to the user because there is usually more time for feedback for usability and functionality testing,” Brookstone says. The speed at which meaningful use was implemented is another consideration. “The vendors were under a lot of pressure to meet meaningful use requirements, he says, “and the systems have not often kept up with the usability requirements of the clinicians. Some processes that might have taken one or two clicks might have taken 2, 4 or 10 clicks under the new process to get it done. As a result, the systems have not been optimized.”

Many of the efficiencies built into EHRs are achieved in front-office operations, Kosierek adds. “Those efficiencies do not necessarily translate to the doctor in the examination room. And since the doctor pay the bills, they also want to see benefits from it.”

Examine the true costs

Experts also want physicians to analyze all of the costs associated with a new system if they are implementing for the first time or changing vendors. The analysis should include:

Hardware: desktop computers, tablets/laptops, database servers, printers, and scanners

EHR software: Potential costs include EHR application, interface modules, and EHR upgrades.

IT support: Implementation assistance costs could include IT contractor, attorney, electrician, and/or consultant support; chart conversion; hardware/network installation; and workflow redesign support.

Training in how to use the EHR and associated hardware, and how the EHR will create new workflows.

Ongoing network fees and maintenance: Potential ongoing costs include hardware and software license maintenance agreements, ongoing staff education, telecom fees, and IT support fees. Some practices may need to hire IT operations staff, clinical data analysts, or application analysts.

Associated fees to access or transfer your data.

While EHR-related costs vary widely based on geographical location, size of practice and type of system, ONC offers these estimates:

In-office system:

Upfront cost: $33,000

Yearly cost: $4,000

5-year total cost of ownership: $48,000

SaaS/Web-based systems

Upfront cost: $26,000

Yearly cost: $8,000

5-year total cost of ownership: $58,000

In Medical Economics 2-year EHR Best Practices Study, 29 reporting physicians estimate implementation costs (outside of the costs associated with purchase of the system) at $7,610 in February 2013.

Review the end-user licence agreement

While the end-user license agreement is typically created to benefit the vendor, Kosiorek says, most contracts can bend.

“I have not encountered a vendor who is not willing to negotiate terms of the contract,” he says.

Look at payment terms closely, and schedule them according to task completed.

While training might go faster the second time around, factor in time to customize the system and train. This process should take six months, Kosiorek says.

Words of caution

For most physicians, the goal when implementing an EHR system  is to marry the system with your processes. Don’t speed date. Do your homework and take a thoughtful approach to system selection that can come the closest to meeting your processes.

“I think speed would be your enemy,” ONC’s Reider says. “It is important to act deliberately as you implement healthcare information technology. Build insights from others. Don’t step in the same puddles,” Reider says. “Use this as an opportunity to think very carefully about what your current workflow is and how information technology can be optimized to leverage your work processes.

“If you do that and leverage health IT toward practice transformation, that is doing it right. If you plug in a computer and think that will solve it, you are going to have problems.”