May 14, 2007

Manage Your EHR Expectations
By Carolyn P. Hartley
For The Record
Vol. 19 No. 10 P. 8

For the last five years, HIT industry insiders have tried to analyze whether this is “the year” that the bell curve of physicians who move from the inquiry stage to full-fledged adoption of electronic health records (EHRs) takes an upward turn.

The analysis isn’t just about projecting revenues—it also helps EHR software companies sustain and retain their current customers while managing the expectations of new, guardedly optimistic purchasers.

If physician attendance at trade shows; their participation in polls, surveys, and listservs; their push for medical associations to assist in EHR vetting and selection; and better questions from educated buyers are any indication, the next two years will produce a swell in the EHR adoption bell curve. That’s good news for the vendors and HIT advisors who have been on a white-knuckle ride for years, holding on until adoption becomes more commonplace.

It’s also good news for physicians nearing adoption who now have more colleagues with which to exchange tips, techniques, and war stories. However, it’s not-so-good news for the tire-kicking practices holding out for HIT to be the hospital’s problem. Buyers-agent hand-holders are still readily available, but now that hand comes with a service fee.

Market changes call for customer adaptation. An examination of several industry-recognized studies sheds light on how physician practices can adjust EHR expectations for 2007 and 2008.

1. Expect the EHR vendor to pursue your loyalty.
EHR companies are actively looking for ways to earn and secure your business, but loyalty is the name of the game. Unless yours is a practice with at least 25 physicians, don’t count on EHR companies to extend the pampered treatment. There are scores of educational conferences, Web tutorials, and audio conferences—many cosponsored by vendors—to provide guidance on EHR selection and workflow change management. Vendors that once paid for names of physicians no longer want just leads. Today, they seek dedicated, enthusiastic, and qualified buyers. And since many vendors have a four- to six-month waiting list—based on just a 23% adoption rate—they can afford to be selective. As a result, while a practice is qualifying the vendor, the vendor is also qualifying it.

Are you a use-it-for-30-days-and-return-it customer? Or do you really want to make improvements in reimbursement, quality performance, and office efficiency? If you’re the latter, you’re the star they seek to do business with.

2. Implementation will make or break your investment.
Want to quickly lose anywhere from $100,000 to $6 million? Implement that EHR puppy yourself.

Quality control of the implementation process is a big concern for EHR companies. They don’t have time to project manage the entire transition process, but they do have time to manage the installation and software training. As players in an adolescent market, they can afford to “cherry pick” the implementations they want to manage internally. As a result, forward-thinking EHR vendors handpick reliable, dependable, and knowledgeable HIT consultants.

HIT and implementation consultants, the best of whom are booked six to 12 months ahead, are there to improve a practice’s bottom line. Their mission is to guide newcomers through redesigning an efficient workflow, project managing the implementation, and coordinating the interfaces with labs, pharmacy, and imaging—yes, practices are responsible for those, not the vendor.

EHR companies are increasingly teaming with consultants to manage the implementation and act as project manager for scheduling interfaces, training, workflow redesign, patient slowdowns, patient communications, and so forth.

To find such vendors, check out your society’s medical meetings or sift through last year’s conference literature. HIT consultants waiting for the market to ripen are highly visible at trade shows and conferences. If the consultant has been invited to speak more than once, or if your colleagues offer high praise for their implementation experience, the wait to work with that consultant will be well worth the investment.

The consulting market also continually seeks implementers with insider clinical knowledge and some technical background. Nurses, billing consultants, practice administrators, or physicians can represent the vendor through the implementation and customer relations process.

Top vendors also hand-select and train implementation consultants to be knowledgeable about their own software, so be sure to ask your vendor for a referral list.

3. Look to your referral network for collaboration.
Physicians, especially those in small and midsize practices, are figuring out—with the help of good health law attorneys—how to establish virtual independent physician associations to share the cost of the EHR and implementation staffing. Eventually, these physicians become “super users” or coaches for the second and third waves of clinicians to come onboard. Additional costs worth managing include those for training, hardware purchases, interfaces, around-the-clock technical support, upgrades, security features, and shared staff.

4. Give specifics about your practice before asking for a proposal.
Recently, while reviewing contracts from three different vendors for a cardiology practice, a client came to realize she was not comparing apples to apples. Instead, elements inside the contract were more like comparing similarities between a gorilla, a tree, and a pear.

Inside the vendor’s contract, practices will find an explanation for what they are purchasing. Hardware costs often include a new server, hubs and switches, wireless access points, routers, monitors, transfer stations, user licenses to make the hardware work, and a few wireless tablet PCs and smart phones. Software costs are likely to spell out the user licenses, costs to uninstall an existing practice management system and install the vendor’s system, bidirectional interfaces, clearinghouse, claims editor, training, and travel.

The sum total of those contracts will range from $85,000 to $350,000, but the variance isn’t necessarily because one vendor charges more than the other, which they do. Perhaps you don’t want to swap practice management systems. The variances are in your court. Practices will have greater control over the proposals if they provide an inventory of their current features and a list of needs. Then, incorporate those lists into a request for proposal that is sent to the top three vendors.

Avoid making the list too technical—practices don’t have to learn the difference between a virtual private, wide area, and local area network. Instead, the list must explain what features are necessary. For example, the practice may want to do the following:

• access medical records from the hospital, home, and office;

• send prescriptions electronically;

• download lab results into the medical file by the time patients are seen in the exam room;

• obtain licenses for three full-time physicians and two part-time nurse practitioners without paying full fare for the part-timers;

• verify that the payer received a prior authorization so denied claims can be pursued; or

• make allowances for three vintage 286-megabyte computers, a tablet PC, and wireless smartphones and pagers.

Without a specific wish list, estimated costs will reflect the vendor’s prior receivables for similar practices. But that approach fails to take into account that EHR costs are stabilizing. Who wants a proposal based on inflated costs?

HIT consultants can help categorize wish lists, prequalify three qualified vendors, act as a buyer’s agent, and obtain three reasonable estimates. There will still be a variance, but now it’s possible to compare real costs rather than respond to a proposal written for the vendor’s advantage.

5. Manage the change process
There is a close connection between change management, which focuses primarily on people’s attitudes and comfort levels, and workflow processes. For example, healthcare requires a considerable amount of documentation. Until now, that documentation was stored on paper, and transferring paper from one workroom/closet/storage shed to another causes significant slowdowns, inefficiencies, and cost increases. It takes time to completely adapt to a paperless practice, but even the most resistant physicians have vowed never to go back to paper once they realized the improved efficiencies.

6. There’s room at the table for more EHRs
As the industry transitions from an emerging market to an adolescent market complete with acquisitions, mergers, and bankruptcies, seasoned investors have found EHRs to be a more stable home for their funds than three years ago. Depending on their threshold for risk, investors compare whether to purchase a smaller piece of a mature EHR or a larger piece of an emerging EHR.

The market has plenty of room for new EHRs, but they have to be debugged and solve a specific problem to find room in the vendor mix. The stakes are also higher for market entry, but the rewards are commensurate with the risk, especially since the Certification Commission for Healthcare Information Technology certification ensures the presence of more than 150 functional components.

In summary, build a tailored proposal before purchasing an EHR. Both the practice and EHR vendor will benefit by eliminating the needless time that would have been spent in pursuit of each other. Once the purchase is made, count on the EHR vendor’s loyalty, and that relationship will flourish if the implementation is well-orchestrated and managed—skills highly prized by both vendor and practice. Then be a coach and help other practices manage their expectations, especially as EHRs go about the business of changing the practice of medicine.

— Carolyn P. Hartley is president and CEO of Physicians EHR (www.physiciansehr.com) and lead author of EHR Implementation: A Step-by-Step Guide for the Medical Practice.