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Overcoming resistance: Towards the Electronic Patient Record conference

Deciding what information technology software to buy could be easier than getting your practice to use it. Experts offer some advice.

By — Posted July 10, 2006

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Mark Fracasso, MD, a gynecologist in Alexandria, Va., can tell you that his two-doctor office is proof that not every physician, even in the same office, uses information technology to its fullest extent.

Dr. Fracasso said he uses electronic prescribing technology to handle 80% of all the prescriptions he writes, putting the other 20% on paper because of patient preferences. Meanwhile, his practice partner usually uses the technology only for refills.

"I just want to emphasize that just because one physician is interested in using [technology], it doesn't mean that the other will do it." Dr. Fracasso said. "That's going to happen but it's not going to happen right away."

Dr. Fracasso made his remarks at the recent Towards the Electronic Patient Record conference at the Baltimore Convention Center, where about 3,000 physicians, physician office managers, consultants and vendors gathered. They were there, in part, to brainstorm for answers to the question: How do you make sure physicians are getting the most out of their technology?

The broad answer is that physicians must prepare themselves and their staffs well before the purchase of a system for changes, both positive and negative, that will occur with the implementation of new information technology. A theme that ran through many of the educational sessions was that, as difficult as it is for physicians in small practices to drop $20,000 to $30,000 for electronic medical records software, writing the check is actually the easiest part of automating a doctor's clinical practice. The tough part is getting everyone in a practice to use the technology, considering physician and staff resistance not only to the new system but also to changes to the day-to-day routine that system brings.

It's not unheard of for a practice to go through the costly process of deinstalling their EMRs down the road -- junking the system after staff members have stopped using it -- according to some physicians who spoke at TEPR, held in mid-May. With advance preparation, the chances a system will fail or merely be underused go down significantly, experts said.

"A lot of times you see offices trying to put in computers when they don't know what they are doing to start with," said Allen Wenner, MD, a family physician in Lexington, S.C., and a vice president of clinical applications for Columbia, S.C.-based Primetime Medical Software. "That's why education is so important. I recommend a minimum of 50 hours of CME in [medical informatics] before a physician even considers looking at buying an EMR."

That instills confidence in physicians that they made the right decision to get an EMR and makes them stick with it when problems inevitably arise, Dr. Wenner said. "They think they can just write a check like they would for a practice management system and as a result, we see a disaster and we see resistance because they are going to tell all their friends about how much they spent for a system that [they think] doesn't work."

John C. Joe, MD, MPH, assistant medical director of information services at Texas Children's Hospital and medical informatics specialist at the NASA Johnson Space Center in Houston, said many doctors think that EMRs should reflect how they work. But Dr. Joe said that mentality is wrong because "most clinics have flaws in their processes, and if you don't identify and fix those first, we have two pitfalls."

"One is that you automate a faulty process and do the wrong thing faster in the EMR. The other thing, which can potentially be worse, is that you don't identify a faulty process, and then when you automate and people run into problems, they start blaming the software rather than the flaw that existed before."

To successfully implement and use an EMR, physicians must figure out all their and their employees' workflows before buying a system, Dr. Joe said. To identify workflow processes that have to be redesigned, outside experts can offer an objective evaluation, he said.

Small practices also can educate themselves about EMRs by arranging for medical schools to send a medical student to spend the summer helping them understand, implement and use EMRs in exchange for the student seeing how doctors work, Dr. Wenner said."It's wonderful for the student because he gets to see how [doctors] practice medicine and gets to understand the workflow. The older physicians get to learn from the medical student the techniques of information management that only a medical student or other physician could teach," Dr. Wenner said.

For a practice to implement an EMR successfully, both the lead physician and office manager must be on board from the get-go, said Michael C. Tooke, MD, chief medical officer of the Delmarva (Md.) Foundation, a quality improvement organization that has a federal contract to help small practices in Maryland and the District of Columbia select and implement EMRs at no cost to the practices. That's why Delmarva requires the lead physician and office manager of a practice to sign a statement declaring that they are committed to and will devote resources to implementing an EMR before it will agree to help any practice, he said.

"When there's a difference of opinion of what needs to happen [or physicians are humoring a colleague who's gung-ho on EMRs], you are really pulling the stopper out of the bottle -- and hope -- before you can really get started," Dr. Tooke said. "If the partners aren't on board with the transition ... it's going to make this a very difficult situation for [an implementation] to succeed."

To give resistant physicians and staff time to come around, practices should set a date by which everyone will be expected to use an EMR, Dr. Tooke said. If they don't get on board, "at some point ... you just have to say, 'This is what our practice is going to do. If you want to be part of our practice, this is what you're going to do. If not, good luck.' "

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ADDITIONAL INFORMATION

Avoiding failure

As part of a three-year contract with the Centers for Medicare & Medicaid Services, quality improvement organizations have been advising small- and medium-sized practices on how they should select and implement electronic medical records. Borrowing a page from David Letterman, Michael C. Tooker, MD, chief medical officer at Delmarva Foundation, a Maryland-based QIO, entertained attendees at the Towards the Electronic Patient Record conference in Baltimore with a list of the top 10 things overheard when an EMR system fails in a small practice environment:

10. "I'm using my buddy's homemade system."

9. "My partner doesn't want to do it."

8. "I haven't really broken the news to my office manager."

7. "Just tell me what system to buy."

6. "The vendor says, 'The next version will do that.' "

5. "I don't need my lawyer to look at the contract."

4. "Good news. I saved a bunch of money on my service plan."

3. "We're going to scan every piece of paper."

2. "Some of us are still going to do paper charts."

1. "Who needs quality improvement? I always do what needs to be done."

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Making the right choice

Because buying and implementing an electronic medical or health records software system might be the largest capital expense physicians will incur, they are understandably nervous about selecting the right one for their practice.

In 2004, Tucson-based Arizona Community Physicians selected an EMR that will cost the 96-doctor primary care group $15,000 annually per physician over five years ending in 2009 -- more than $7 million total.

After sharing his group's experience with attendees of the 2006 TEPR conference, Kenneth G. Adler, MD, a family physician and medical director of the group, sat down for an interview with AMNews:

Does the size of the practice make a difference in how doctors select an EMR or EHR?

I think the approach actually should be similar in terms of the steps: defining what your goals, needs and wants are, getting information about what is available, and doing a cursory initial assessment of [vendors] you want to investigate more and specifically requesting information from them. Large practices will want to do that through an RFP process [request-for-proposal, in which vendors submit bids]. Smaller practices can do that through, maybe not a huge RFP, but with a pared-down version describing who they are, what they are, and maybe send the information to the vendors, asking for responses to certain questions that they have.

Some practices take two to three years to select an EHR. Is that necessary?

That's too long. A reasonable time frame is six to 18 months. Six months is probably about as fast as someone should go because if you're doing it faster than that, you're likely rushing the process and not taking enough time to learn what's available and getting adequate responses. If you take more than 18 months there's something going on in your decision-making process that's slowing you down.

What can doctors do to ensure they select an EHR within a reasonable time?

There are published ratings of systems [available]. They can look at those and just choose to look at the most highly rated systems. ... The Certification Commission for Healthcare Information Technology [a vendor, health plan and medical association-funded group] will be certifying ambulatory EHRs, and it's setting the bar fairly high in terms of functionality. So I think any product that comes out with CCHIT certification will definitely be worth looking at.

What things should doctors consider as they are about to sign on the dotted line?

The important thing in structuring a contract is to tie payments to certain performance criteria. So you don't want to make the payment all up front. You want to make sure that the final payment isn't made until ... [vendors] deliver on the implementation part -- whatever they agreed to do.

Will vendors agree to that?

I wouldn't buy any EHR from a vendor that didn't accept those terms.

Does it matter what EHR physicians get? Don't they all do the same thing?

Right now there's still a fair amount of diversity in what's available. So again it depends on your goals. If you're interested in doing pay-for-performance, for instance, you want an EHR that has reporting capabilities, that will capture discrete data that's useful that you can query on. If you want to prescribe electronically, it's obviously very important that [the system] has that capability, and you will want to look specifically at how smoothly that works.

Any other advice?

If physicians aren't familiar with [Medicare's] Doctors Office Quality-Information Technology program (link), I'd encourage them to look into it. This is a fine program available to doctors in small to medium practices to help them select and implement an EHR. It's one of the only few freebies out there, and I'd encourage people to take advantage of it.

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Lessons learned from the field

At least in the electronic prescribing world, there can be such a thing as too much choice.

The Southeast Michigan Electronic Prescribing Initiative, sponsored by Detroit's Big Three automakers, learned that lesson a year ago when it offered financial incentives to help doctors buy any of a dozen systems.

"What we learned is that we had too many vendors," which left physicians confused about what system to buy; many of them did not participate in the program because they feared making the wrong choice and didn't want to spend the time to sort through all the systems, said Richard Datz, the program's project manager, who spoke in May at the TERP conference.

"We did not do a great job providing assistance to the doctor in making that choice," Datz said. "What we're trying to do when we relaunch the program [this year] is ... provide more guidance and limit the number of vendors. We're still saying that you can choose whichever vendor you want, but these vendors we know a lot about. We're going to require [our certified vendors] to have some standards relative to training, support, etc., to make that process a little bit easier for you."

That strategy proved very successful for BlueCross BlueShield of Massachusetts. By offering doctors a choice of only two vendors and working closely with those vendors "in terms of training, support and outreach" the plan was able to sign up 3,400 physicians by the end of 2005, said Jessica Fefferman, program manager of eHealth Innovation at the insurer.

Still, recruiting physicians wasn't a cakewalk for the plan. "Initially, we went out and did these large forums where we invited physicians to come to learn about the technology, and [those] were not very successful," Fefferman said. "It's just not really reasonable to ask physicians to come to you. You really need to go to them."

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