Avoiding EMR meltdown: How to get your money's worth

About a third of practices that buy electronic medical records systems stop using them within a year. A little homework can help ensure you buy one that will work for you.

By Tyler Chin — Posted Dec. 11, 2006

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Barry D. Hendrix, MD, learned a very expensive lesson -- not all electronic medical records systems work for everybody.

Last year, the Paragould, Ark., family physician spent $100,000 -- more than he paid for his house in 1995 -- to buy an integrated practice-management and EMR system for his two-doctor practice. The practice-management component has a few problems, but it's usable. The EMR is a different story. Dr. Hendrix is completely dissatisfied with the performance and the vendor service. He stopped using the EMR after less than two weeks.

"I thought I was paying for a Ferrari, but what I got was a bag of parts," Dr. Hendrix said. "To see $100,000 just disappear. ... That's a tremendous amount of money to me. Had I been a new doctor coming out of a residency program or just out of medical school, I'd have gone bankrupt. The only thing that's kept me solvent is that I have been in town for years and have already established myself. But any new person wanting to start a practice and wanting to do it this way would be placing themselves in great jeopardy."

Dr. Hendrix is hardly alone in initiating what those in the technology business call a de-install -- stopping use of a software within six to 12 months after its installation.

There are no empirical data or surveys measuring how many de-installs occur annually, but people in the industry estimate that 20% to 33% of EMRs fail within a year of their implementation because physicians are unhappy with the systems. With industry estimates showing that up to 80% of practices have not yet made the EMR leap, there are a lot of first-time buyers who could fall into the de-installation trap.

Sometimes everything grinds to a halt because the EMR selected is just a bum system. Sometimes it hasn't been installed correctly, so it doesn't work to its potential. Sometimes it just doesn't fit the practice's needs. Sometimes customer support is unsatisfactory.

Sometimes, even after physicians meticulously study and test new systems, things still don't work. But often, the reason for a de-install is that physicians did not take enough time to evaluate and figure out how to improve their office's workflow processes. That is a step many doctors fail to do or don't do well, which dooms their ability to select the right system for their practices, experts say.

"It's largely, I think, due to a lack of education," said Allen Wenner, MD, a family physician in Lexington, S.C., and co-founder of High Performance Physician Institute, a Raleigh, N.C.-based nonprofit organization that offers EMR education classes to physicians.

"People don't know what they are getting into. They think it's going to be one thing, and it's something else. And they aren't happy," Dr. Wenner said. "They don't follow up, they don't talk about it, they don't do workflow analyses. They don't do anything, and that's a de-install."

Smaller practices are more vulnerable to a de-installation than larger practices because they "lack the capacity to really do the level of detailed workflow and requirement analyses, and then compare that to various products," said David Brailer, MD, PhD, co-chair of the American Health Information Community, a public-private advisory body that is guiding the Dept. of Health and Human Services on the development of a national health information network.

To help doctors and minimize the risk that their EMR purchase will blow up on them, HHS in 2005 awarded a multimillion-dollar contract to the Certification Commission for Healthcare Information Technology to develop certification criteria for ambulatory EMRs. That will help doctors know what the products do, Brailer said. But it won't guarantee those products are what they want.

The federal government relaxed the Stark rule to allow hospitals to provide EMR technology, training and support to physicians so they can get systems with less worry about financial disaster if things go wrong, said Dr. Brailer, the former head of the Office of the National Coordinator for Health Information Technology.

Minimizing risk

There are a number of things doctors can do to minimize the risk of a de-install, experts said. In addition to doing a workflow analysis, those tasks include asking yourself whether you and your staff are ready to change how you work. If you're not ready for changes that an EMR will bring -- for example, orders entered by physicians instead of given to staff -- your implementation will flop, experts said.

They also recommend you seek assistance from consultants, including Medicare's Doctors Office Quality-Information Technology program, which is free and designed to help small practices select and implement EMRs.

Once you're leaning toward one particular system, experts suggest you:

  • Locate and personally visit sites that are the same size and specialty as your practice and that use the software you're considering.
  • Make sure both doctors and staff in those practices are using the system.
  • Ask those physicians whether the vendor or the company that installed the EMR was responsive and whether it has done what it said it would.

Dr. Hendrix said he followed some but not all of those recommendations before he signed a four-year contract in 2005 to acquire a system from NextGen Healthcare Information Systems Inc.

He received assistance from the DOQ-IT program in Arkansas. He also talked over the phone with two local practices that used NextGen Healthcare's system. But Dr. Hendrix said he made two key mistakes in his research.

The first was that he didn't visit the sites in person. The second is that the groups he talked to were outside his specialty. Dr. Hendrix figured he would be OK, because NextGen Healthcare was a nationally known and reputable company.

Verify everything

But the biggest mistake, Dr. Hendrix said, was failing to have an attorney review the contracts. "My advice to anybody who's wanting to implement an EMR is, 'Don't trust anything that somebody tells you -- verify everything.' "

Dr. Hendrix had problems right from the start, he said. The reseller NextGen used implemented the billing and EMR systems nine months apart, although they were supposed to go live at the same time. When the EMR finally went live, it had links that led nowhere, he said. It also generated notes filled with asterisks and pound signs.

NextGen Healthcare said Dr. Hendrix is responsible for the failed implementation of its EMR. A written statement a company spokesman e-mailed to AMNews said "NextGen Healthcare is disappointed Dr. Hendrix has decided not to complete installation of our EMR system, especially after completing a successful implementation of our Enterprise Practice Management System.

"We believe, based on numerous e-mails received from the practice, that its high staff turnover and subsequent lack of time needed to adequately participate in the implementation/training process were likely factors in this decision. At one point, the practice did request to work directly with NextGen instead of this reseller but did not take the steps necessary -- a formal letter requesting that NextGen provide all training and support was repeatedly asked for and never received -- to make this change."

NextGen Healthcare reviewed the training and implementation processes provided by the reseller, Interface Healthcare Information Systems, "and found them to be sound and effective," the statement said. Interface did not respond to AMNews' requests for comment.

Dr. Hendrix said his practice indeed had staff turnover. But he disputes the rest of NextGen's statement.

Stuff happens

De-installation is not always such a contentious process. The forecast of pay-for-performance drove Steven W. Harrison MD, a solo family physician in King City, Calif., to buy an EMR in August 2005. He is already seeking to replace it because it's too hard to use.

"It's a versatile system, but it's too complex, too hard to put together," Dr. Harrison said. The vendor has been responsive in addressing issues, but there have been some unrelated technical glitches it has been unable to resolve, despite its best efforts. "There are no bad guys here," he said.

Experts such as Dr. Brailer say they expect the de-installation rate to go down as more physicians get more experienced with EMRs, helping them make better decisions on what to buy. Experts also say de-installation horror stories shouldn't prompt other doctors to rule out buying a system.

Dr. Hendrix isn't letting his first EMR experience sour him on technology. He bought an EMR from eClinicalWorks, and expects the system to go live this month. This time, he said, he made site visits to family practices using the product. He also hired a lawyer to review the contracts with eClinicalWorks and its reseller. Both companies have been professional and responsive, he said.

"If I can be of help to any other physician, even as a bad example, so be it," Dr. Hendrix said. "I'd hate my colleagues to go through what I went through."

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Getting an EMR that works for you

There are several reasons why an implementation of electronic medical records software might fail. There are also ways to improve the odds for success.

Reason for de-installation: Not ready. Solution: Are you willing to put in the extra time and effort that implementing an EMR requires? Are you willing to change the way you and your staff practice? Are you comfortable using computers? Is every doctor and employee in your practice on board with using the EMR? If you answered no, stop there.

Reason for de-installation: Wrong product. Solution: It's essential you analyze the 25 to 30 major workflow processes in your practice, determine how to improve them, and make sure the EMR products have the features you need. Ask vendors to demonstrate their product using scripts you developed. See if the system is easy to use.

Reason for de-installation: Poor vendor support. Solution: Hiring a lawyer to review the proposed contract is important, but it's more important to check out references that didn't come from the vendor. You can find those on electronic forums used by your peers. Ask how responsive the vendor is and how good the support is. Ask vendors to provide tech support statistics, such as the average wait time for response and for resolution.

Reason for de-installation: Vendor goes out of business. Solutions:

  • If vendors are publicly held companies, documents will be filed with the Securities and Exchange Commission. If vendors are privately held companies, check financial stability by asking for recent tax returns. If they decline, even after you offer to sign a nondisclosure agreement, reconsider whether you want to buy from them.
  • Ask vendors how they derived their revenue figure. Is it from sales of software, hardware, networking, implementation or maintenance fees? For example, a vendor may tell you it's a $50 million EMR company, but if only $10 million of that comes from software sales, it's really a $10 million EMR firm.
  • Ask people in the industry or on listservs what they know about the vendors' finances. Are the sales and support staff still there when clients call? High turnover could indicate problems.

Reason for de-installation: Cost higher than anticipated. Solution: Ask vendors which features and services are covered and which are not; what is extra and how much.

Sources: David Brailer, MD; Max Burger, MD; Darin M. Camarena Health Centers; e-MDs Inc.; Steven W. Harrison, MD; Barry D. Hendrix, MD; Informed Partners LLC; Sterling Solutions; Allen Wenner, MD

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AMA offers EMR info clearinghouse

The American Medical Association has launched a Web site all physicians can use to learn about electronic medical records issues and how to evaluate and implement systems for their practices.

The goal of the AMA Health Information Technology site, launched Nov. 1, is to provide a centralized information clearinghouse offering doctors an easy, convenient way to access information about EMR systems.

"We think that there are a lot of organizations out there that have done a lot of good work, but your average general physician doesn't have the time to go out and find that information," said Amanda Ervin, director of health information technology initiatives at the Association. "It's a starting point for physicians to start thinking through some of the issues that are around information technology from a policy side and also from a more practical operational side."

The site (link) includes content developed by the AMA.

Other useful sites include:

  • The American Academy of Family Physicians' Center for Health Information Technology (link). Some content is restricted to members.
  • The American College of Physicians' Medical Computing Homepage (link). Some content is restricted to members.
  • The Certification Commission for Healthcare Information Technology (link).
  • The California HealthCare Foundation's iHealth and Technology resource center (link)
  • The Office of the National Coordinator for Health Information Technology (link).

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