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

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."