The EHR switch: Why it may be the best change your practice ever makes

Switching your electronic health record (EHR) system is expensive, time-consuming, and disruptive to your practice. But if, as a physician, you are stuck with a system that has become unmanageable or negatively impacting your operations, converting could be the right solution no matter the cost.

With the conversion to the International Classification of Diseases-10th Revision, meaningful use 2 (MU2), and pay for performance on the horizon, you need an EHR system that works for you and makes your life easier, not harder.

My solo internal medicine practice in Boardman, Ohio has switched systems three times. I wanted to share some of the insights our team learned about this process.

In 2007, I purchased my second server-based system, after seeing a demonstration of the system’s features by a salesman. During the pitch, he made big promises about the system’s functionality, yet few were realized over the next five years of use. Upgrades were delayed; users were on different platforms; I was unable to attest to MU1 in 2011, and there was no Physician Quality Reporting System (PQRS) registry. The costs for fixes and hardware kept mounting.

Despite various problems, I liked some of the core features and functions of the system. I built and customized templates; I could easily navigate through notes, orders and prescribing. With training, my staff became adept at using the system. I really didn’t want to switch, but the system could not get the practice to attest to meaningful use without additional costs. So the decision was made.

As part of the search for a new system, I started to investigate system features, review customer feedback, examine the track record of vendors, and, very importantly, consider the financial stability of the company. Also, I didn’t want to rely just on demos from vendor sales people, so I decided to examine the published white papers about various systems. However, when I completed a form, the phone calls started, and I received literally hundreds of e-mails from overly aggressive salespeople.

READ: Top 50 EHR software companies of 2014

Instead of vendors telling me what I wanted, I decided to build a wish list of essential features for my practice’s next system. While there is no perfect system, I felt we could get closer to identifying the right system to meet my practice’s needs. I received input from my office manager and key staff members. Here is my list:

Next: Cloud-based practice management system

Cloud-based practice management system

I no longer wanted the responsibility and expense of keeping and maintaining a server on my premises. All of the practice’s other systems were server-based, requiring expensive upgrades or replacement. The practice also had to contract with an information technology professional to maintain and manage the servers.

Pain-free upgrades

While upgrades are a natural part of software development, we looked for a system that would have significantly fewer disruptions to our practice operations.

Revenue-cycle management

I had talked to quite a few doctors about their experiences with revenue-cycle management (RCM) and decided that I was ready to adopt this kind of service.

Some of RCM’s advantages are that it enables the seamless transition of coding and the submission of claims, thereby reducing the number of errors transferring billing information from one system to another. Also, if my biller quit, where would I be?

Once we got the hang of it, RCM sped up the “normal” billing process. The practice reduced rejected claims by 85% using RCM because of the scrubbing mechanisms in the system. I’ve seen a dramatic decrease in my accounts receivables, improved claims submission time and dramatically reduced the remittance time of submitted claims.

READ: 10 tips to access revenue cycle management vendors

I get live eligibility at the time an appointment is scheduled, one week prior and the day of the visit. The practice can immediately access copay and deductible information. Claims go out on the day of the visit and payment reminders to patients go out automatically.

Meaningful use certification and PQRS registries

Although the cost of using an EHR far exceeds the $44,000 reimbursement we get for meaningful use, the ability to integrate and share data with other entities improves the delivery of patient care. We may feel forced to be part of MU2, but I really think that interoperability (when functional) will vastly improve continuity and transition of care by speeding communication among facilities and other providers.

The net effect will be to reduce redundant testing, improve treatment, and produce better overall patient care.

Quality metric dashboard with ticklers for preventative medicine

Quality metrics help guide the practice and improve the quality of care that I provide patients. And the ticklers warn and advise me on the need for vaccines, colonoscopies, and mammograms that are often overlooked.

As a result of the quality dashboard, which was high on my priority list, our practice attested to MU1 in 2012 and 2013. In 2014, I was one of 50 physicians in the U.S. to attest to MU2 in the first quarter of the year. I call my dashboard “meaningful use for dummies” because it has simplified the process for me.

Ability to interface with labs, imaging and other point-of-care tools

I wanted a system that would drop lab results directly into a patient’s chart to avoid data entry errors and speed our accessibility to diagnostic information. I also wanted the system to upload directly into a dashboard to make tracking of practice guideline metrics accurate.

Onshore customer service and support that is focused on our practice needs

When I have a problem or an issue, it is important to have support from someone who understands the U.S. healthcare system and the unique needs of U.S.-based physicians.

Strong patient portal

I wanted the system to enable patients to request online appointments, prescription refills and to pay bills without involving additional staff time. I wanted my patients to be able to access the portal easily and maneuver through the portal without a lot of difficulty. I wanted to enhance the productivity of office staff; reducing the number of phone calls and amount of note-taking by receptionists saves time. It allows patients to communicate health measures such as blood sugars and blood pressures accurately and directly to the healthcare team.

Automated appointment reminders for patients

I also wanted to decrease the number of no-shows and increase adherence to follow-up visits for chronic conditions.

Reasonable outlay of costs

I wanted a system that would require a minimal investment in hardware and software.

Viable company that would be around in 20 years

I was looking for an EHR company with a strong financial track record and one that invests in research and development, because it decreases the risks of a company going out of business.

Next: Lessons learned

Lessons learned

Once we had our criteria, it helped our search efforts. But the process still took months to complete.

After we made the selection, the real work began. We began training; I started customizing templates. We prepared the practice financially for an anticipated loss in productivity and cash flow. And while the go-live stage remained a challenge, each day became easier. Ultimately, it took the practice four months for patient visits to return to pre-switch levels.

It’s not easy to make the switch no matter how much the practice prepares, but it was worth the effort. Sticking to these 12 criteria allowed us to make the right choice. Although our current system is not without issues, we have a solid system on a solid platform that more than meets my needs.

Here are eight lessons our practice learned when switching systems.

1. It all starts with the end-user license agreement

First, have a lawyer review your old contract, and review the new end-user license agreement (EULA) before you sign. Make sure you have a EULA signed and training completed before notifying your current EHR vendor of the switch. Consider converting your records from your old system into the new system and explore the cost associated with the change. Make sure:

• you have an out clause;

• you understand the terms of the out clause, and that the separation is acceptable to your practice and the vendor; and

• the features, training and support promised in the sales process are actually referenced in the contract, at the agreed-upon price.

2. The data: to convert or not?

Is it worth converting information that may be full of errors and that may cost a small fortune to convert? Data mapping and data conversion are costly. Think through these issues before you sign a final contract. Every time I have switched systems, we had a system in place to re-enter the data. This may seem like a lot of work, but for our practice it was an easier way to manage the conversion.

3. Build a cash reserve

I built up a cash reserve to cover two months of operating costs, so we didn’t have to take out a line of credit. I did not draw a paycheck during this time period. I knew from my prior experiences of converting systems that there would be a drop in revenue due to productivity loss and the delay in billing through a new system.

Prepare financially for the decrease in productivity the practice will experience. Your income will drop. The conversion will also cause a delay in submitting claims-
another problem to consider.

Next: Should you jump in or ease in slowly?

4. Should you jump in or ease in slowly?

Although I have talked to people who have tried a slow migration between EHR systems, I feel the best strategy is to transition all at once.  Jump in and hold on! It feels like you are whitewater rafting during the go-live phase, and you will be paddling against the current for the next three months.

5. Don’t believe the sales pitch

Would you buy a used car without checking collision reports or getting an independent assessment? Insist that your vendor give you the names of doctors who are using the system. Ask them for a list of 20-25 doctors so that you can pick physicians to contact.  Often the vendor will try and persuade you to talk to customers who they know will give them excellent ratings.

Look at the October 10, 2014, issue of Medical Economics to see where doctors rated these systems in an unbiased and unsolicited study.

6. Learn and understand the system

Know the functionalities and capabilities of your EHR system.

Don’t depend on your staff to be the sole power user. Learn the system, so that you can teach your team. It will help build efficiencies. Also, most solo practitioners don’t have the luxury of a full-time, designated information technology person, so it’s important for the practice leader to truly understand the capabilities of the system.

7. Prepare for the loss of productivity and the frustration that goes with it

Preparing yourself, your staff and your patients for the change is half the battle. Expect a decrease in productivity of 30%-50%. Prepare your staff with intense training.

Take steps to boost their morale, because they will probably become frustrated easily. Be ready to communicate to patients the reasons for changing systems and the benefits of the change, including access to a patient portal, improved quality of care with practice guidelines, ticklers for preventive care, e-prescribing, drug interaction checking and drug allergy warnings.

8. Don’t change your workflow to adapt to the system. Adapt the system to enhance your workflow.

I have been using an EHR since 1992, when I started in practice. The market for EHRs is a dynamic place, undergoing great change. Many systems are inadequate, with too few users and the costs to constantly upgrade to maintain certification will drive many vendors out of business.

It might be time to switch when your EHR lacks support, is not MU2 certified, is inefficient or not user-friendly, offers multiple platforms and all users are not on the same version, if you want to add a practice management system with integrated scheduling and revenue cycle management, or when your practice has simply outgrown the EHR’s usefulness.

The biggest lesson of all is, don’t live with a system that doesn’t work for you. You can make the switch, and now might be the right time to do it.