December 26 , 2007

Buyer Be Aware: Issues Surrounding Deinstalling an EMR
By Annie Macios
For The Record
Vol. 19 No. 26 P. 18

There’s no getting around it: Some EMR implementations end in failure. What steps can healthcare organizations take to be prepared in case the worst happens?

When any relationship comes to an end, the logistics of moving forward are just beginning. Questions such as “Where do I go from here?” and “Are my interests protected?” aren’t just for Hollywood’s rich and famous. Healthcare facilities are increasingly faced with the issues related to carrying on after a “break-up” with their electronic medical record (EMR) providers. And just as with other relationships, it may not always be cut and dry.

A trend that has emerged over the last several years shows that nearly as many EMRs were deinstalled as deployed. An EMR application can fail for reasons ranging from unrealistic expectations of what an EMR can do for a particular practice to lack of physician support—or even the vendor going out of business. But what do you do if your vendor closes shop or a decision has been made to deinstall your facility’s EMR? Will your vendor be supportive? And, more importantly, how will it affect your facility or practice?

On the Web site EMRupdate.com, which exists to provide a forum for unbiased, independent EMR discussions, participants report an EMR failure rate of nearly 30%. In comparison, a white paper by Jack Callahan, vice president of corporate development at MediNotes Corporation, estimates that the failure rates for attempting to implement an EMR are closer to 40% to 80%. He states that reasons for failure can include abandoned systems that were unable to be used effectively, those removed for technical or functional shortcomings, integration issues that couldn’t be worked out, or other such incompatibilities.

Amplifying the reality of this observation is the Medical Records Institute in Boston, which for the past nine years has conducted an annual survey of attitudes and opinions about HIT. Their most recent survey results, published in Modern Healthcare, show that nearly 19% of respondents indicated they either have experienced the deinstallation of an EMR system in the past (12%) or are now going through a deinstallation (7%).

“This is a very consistent number throughout the industry, from what I have heard,” C. Peter Waegemann, the institute’s executive director and CEO, reports in the study. “We have been going after why this happens.” When it comes to switching systems, the survey reveals that the trend more often has been to downgrade to less expensive, less complicated EMRs than to more expensive, complicated ones.

So the question is, given these statistics, what can healthcare providers do to protect their data with what is an increasingly likely chance that they, too, will eventually cut ties with their current EMR provider?

A Word to the Wise
Before you choose an EMR vendor, it’s important to consider what type of system you will use: an Internet-based application service provider (ASP) or a client server. Both have advantages and disadvantages. But should the vendor go “belly up” or the EMR not function the way your facility had originally planned, it’s important to be certain that with either system, your patient data is protected.

Bill Bysinger, executive director and CEO of EMRNet, offers some practical advice related to contract issues, finding the right product the first time around, and implementing the EMR in a way that will meet your expectations and have a better chance at being successful.

He first recommends looking at products certified by the Certification Commission for Healthcare Information Technology (CCHIT), a recognized certification body for EMRs and their networks. This nonprofit organization has the mission of accelerating HIT adoption by creating an efficient, credible, and sustainable certification program. Criteria for functionality, interoperability, and security are among the areas of EMR technology examined. Products are tested to ensure that specific procedural steps demonstrate conformance with the CCHIT certification.

In the late ‘90s, there were approximately 300 companies offering various versions of an EMR, but there are now closer to 100 who have stood the test of time. Of these, only roughly 50 have gone through the CCHIT approval process. “So if a provider makes the decision to use a product that is CCHIT-certified, they shouldn’t have a problem,” says Bysinger.

Therefore, there is an advantage to looking only at CCHIT-certified products should you need to break ties with your vendor. “Most CCHIT-certified EMRs have to have standardized capability, and they can output continuity-of-care formatted records that can be read by other EMRs or in a common data format,” says Bysinger. This feature offers protection when an EMR must be deinstalled or the vendor goes out of business.

A healthcare provider should be sure the contract includes a stipulation that if the vendor folds, support of the EMR and all data can be made available in a standard format so it can be moved to another EMR.

Implementation Issues
What is becoming more common is having your EMR deinstalled because of implementation issues. The main problem facilities are finding is that an EMR doesn’t fulfill its expectations or is not properly installed.

“Some EMRs take a year just to install, so ask how long the product itself has been in the market,” says Bysinger. A good gauge is to find one that has been on the market for two to three years, as this provides enough time to properly evaluate how well the implementation has gone. It’s also important to make sure you talk to at least two reference sites about implementation, vendor support, and productivity issues. Implementation includes installation and training, and facilities must ensure that the latter is adequate for the office staff, nurses, and physicians. “Most EMRs fail here,” says Bysinger.

Sheri Poe Bernard, CPC, CPC-H, CPC-P, vice president of member relations at the American Academy of Professional Coders, believes deinstallation often occurs because all the essential parties involved are not included in the EMR purchasing decision. “Make sure you involve your coders in the EMR choice. You might have a great EMR, but it might not be great for the coders,” says Bernard. By involving HIM staff and coders in the selection process, Bernard believes there is a better chance of finding an EMR that will meet the needs of all end users.

Support from the vendor is also key, as well as the ability to achieve productivity gains. For example, if a doctor was seeing 20 patients prior to EMR installation, the technology should minimize the amount of time spent on charting and allow for more patients—possibly 25 to 30—to be seen in the same amount of time.

Bysinger expresses his concern for small practices whose EMR installation is unsuccessful because implementation costs “strap” them more than larger entities with bigger budgets. “A practice with five doctors or fewer gets caught as the victim,” he says.

Allen R. Wenner, MD, vice president of clinical applications design for Primetime Medical Software, says that an EMR vendor going out of business is less of an issue than it was even five years ago. Nevertheless, in this event, he recommends several ways to protect your facility’s data and continue on a forward path.

“It’s important to look at how many clients a vendor has,” he says. In general, even when a vendor goes out of business, a larger vendor with a vast clientele will simply be bought and the records migrated to the new server with relatively little trouble.

Protecting Your Data
Wenner points out how to protect your facility’s data for both ASP and client-server hosting systems. Both have their advantages depending on the facility’s size, and with the right steps taken during implementation, protecting data and moving forward can be done with minimal problems.

Before the Internet became stable throughout the country, EMRs were deployed in a healthcare facility on a client-server platform using a main computer located in the facility. In this scenario, because all the data is held in a database on site, regular back-up of the patient data was an effective protection strategy. In the event the vendor ceases operation, the user simply continues with that software version until the EMR can be deinstalled. Often, a vendor’s escrow code can protect software buyers.

On the other hand, the ASP model offers facilities the ability to quickly set up an EMR with only an Internet connection. The vendor manages the network and software at a remote site, and healthcare providers connect to their EMR over the Internet. Many small practices and physician offices have taken this route because of the lower cost associated with not having to host the data on site. In addition, this method eliminates any worries about losing the data.

However, Wenner warns that the problem with data migration is important regardless. He quotes John Faughnan, saying, “The real cost of an EMR is the cost of exit.” If the Internet EMR company goes out of business and the doctor’s data is on its server, it would be the same as if the paper-based practice office burned down. If a small company is using an ASP Internet EMR, it is important that a provision be made for data archiving, data migration, or insured data recovery.

With technology booming ahead, Wenner sees the EMR as just a small step in what technology may bring in the future regarding how healthcare providers will manage electronic health records. “You always have to be thinking about how you’re going to move to your next EMR,” he says. “Unless you ask the question to start with, you’re not going to have a data migration strategy in place should there be an emergency.”

Wenner stresses to always ask a vendor to provide a back-up that is periodically available in a text file for exportation. Another strategy would be to have periodic on-site archiving of patient records in a standardized format (ie, continuity-of-care record or machine-readable table format). “Talk it over with the vendor to see what would help make an easy exit,” he says. And always ask about the vendor’s migration plan to move forward.

Caveat Emptor
Another issue is the system’s design. Ten years ago, Wenner says facilities would buy best-of-breed products, but this caused a disparity among all the system’s components with little integration. Problems associated with a vendor going out of business were fewer because if one system component no longer had support, the others would not be affected because they were interfaced instead of integrated. Today, with integrated practice management and EMR systems, the risk involved with vendor reliability is higher. Wenner recommends knowing whom you are dealing with and choosing a top-tier vendor. A small vendor with few customers carries a cost greater than a lower price tag.

Wenner, who views the vendor as a business partner, also suggests looking at publicly traded companies or financial data from private companies. Ask the vendor what their terms are for financing the expenditure. “When a vendor wants 90% of his money upfront before anything is in working order, that’s a warning sign,” he says. “A financial hit can be as bad as data loss in some cases.”

Once a decision has been made, Wenner recommends visiting in person as many users as possible and joining a users’ group. This enables a facility to learn from others and be part of a larger group of consumers should any problems occur with the EMR.

Ask how long the company has been in business and what percent of the business is EMR-related. For particular pieces of software, it’s also important to consider what place it has in the company’s portfolio of products: Is the EMR software simply an offshoot of another facet of the business, or is it the main purpose of the company?

By taking all these into consideration, healthcare providers can prepare for the worst, but in the long run, prepare for the best-case scenario simultaneously in establishing a well-thought-out relationship with their EMR provider from the beginning.

— Annie Macios is a freelance medical writer based in Doylestown, Pa.