Should You Scrap Your Legacy EHR?

About 10 years ago, family practice physician Giuseppe Marzella was thrilled to purchase an EHR system for his 10-person, two-physician East Hanover, N.J., practice.

But what began as a quest to streamline a paper-based work flow turned into a staff-wide headache when Marzella's colleagues complained that the technology was too slow and difficult to use. A simple task such as going back to change a field, for example, required sifting through several other fields first.

So the self-described technology enthusiast scrapped the system after just one year.

"It was too complicated and cumbersome," Marzella recalls. "It just wasn't readily accessible; it just bogged down the system."

Marzella's practice made a decision two years ago to try again, giving an EHR system by Amazing Charts a three-month trial run. That was after passage of the federal stimulus bill that included money to encourage practices to purchase EHRs, but before the government had developed rules on qualifying for the money known as "meaningful use."

The new system was much more user-friendly, Marzella says. And by the time CMS announced those rules last July, he felt quite relieved because the vendor committed to making timely upgrades so his practice could comply with meaningful use requirements. Unlike some of his peers, he won’t need to test out another cumbersome EHR.

"I have quite a few friends who are physicians who have adopted an EHR who are now scrapping their systems" in order to comply with the new requirements, he says.

Like Marzella, hundreds of physicians who had already invested in EHRs prior to the release of the meaningful use requirements are now scrambling to bring their current systems into the era of EHR 2.0. Though the issue of getting staff to give up their paper habits may have diminished, these early adopters face other challenges - making sure their EHR is certified, ensuring compatibility with health information exchanges (HIE), and deciding whether investing in a whole new EHR system might be a better option for the future.

So how can you make the best decision without going broke on updates or consulting fees? When is it more cost-effective to purchase a new, spruced-up EHR?

The good news is that by focusing on your long-term EHR goals, such as qualifying for all meaningful use incentive funds and improving patient outcomes, you should save money and time - and experience fewer transitional snafus.

EHR systems: then and now

Not long ago, EHRs were little more than just digitized versions of paper records. Today they are the electronic systems by which a practice collects and transmits patient data, more easily accesses patient records, e-prescribes, and ultimately improves patient care.

"If we go back five or six years ago before any of this meaningful use stuff started to develop, the whole idea and concept was really just to have a digital record," says Susanne Madden, president of The Verden Group, a consulting group that works with practices. "I think the idea of the old EHRs is really [based on] ease of use when putting information in, but not a lot of thought [was given] to extracting information out, particularly when we look at physician systems."

For many smaller EHR vendors that entered the market pre-2010, the primary goal wasn't to create a product that could be used to transmit sensitive patient data.

"For a lot of smaller vendors, it really [was] about just about having nice clean interfaces, being able to access the record in a digital form," says Madden.

In the last 12 months, the priorities of both physician practices and the vendors have shifted. Today, vendors that want to sell to practices must offer EHR systems that are certified to meet the meaningful use requirements to collect federal incentives, because practices won't buy anything that doesn't.

"Basically, the biggest challenge physicians are facing is the whole concept of meaningful use adoption, and the other mandates that are coming down the pipeline, like the ICD-10 changes," says Rajiv Sabharwal, AVP and chief solution architect of the healthcare provider sector at software firm InfoSys. "Now orders have to be computerized, prescriptions have to be computerized."

Old vs. new

The EHR stimulus program, included in the larger economic stimulus package that Congress passed in January 2009, was designed to encourage practices and health systems to adopt and meaningfully use EHRs. Those providers who had already purchased systems prior to the passage of the stimulus would be allowed to cash in on the incentives - up to $44,000 per provider, under the Medicare program - as long as they met CMS' rules demonstrating that they are using their systems in a meaningful way.

With those rules now final, practices that have legacy EHR systems are asking: Should we stick with our existing system, and hope we can use it to meet the requirements, or get a new one?

If you wait until the end of the year to see if your EHR system is up to snuff, you could miss key deadlines and lose out on some of the incentive dollars. That's why the most important thing you can do if you have a pre-meaningful use EHR is to assess whether your system is appropriate for your practice's long-term goals.

"First off, practices need to talk to their EHR vendors," says Madden. "What are they doing? When are they doing it? How's this going to roll out? What are the costs going to look like? And really be able to make a good, solid assessment on what the costs are going to be for the practice. Then compare it to some of the options out there in the marketplace."

When assessing the cost of adapting your existing system versus buying a new one, Madden suggests looking beyond the cost of software. There's also the cost of licensing and maintenance fees, the cost of training, and the potential cost of hiring an IT consultant. There are also expenses that your practice might not know about yet, or ones that vendors are still trying to figure out. Since meaningful use began, many vendors have upped their annual software update-and-maintenance fees. Some have even doubled those fees.

Marzella says one of his physician friends spent $20,000 for an EHR system, only to get hit with an $800-per-month/per-practitioner maintenance fee. It's possible that such a practice might have been able to find an EHR system with a lower monthly fee had it shopped around.

"I would advise [physicians] to look at maintenance costs," says Marzella. "The first time around, I didn't."

And just because an EHR system is newer and certified doesn't necessarily mean it will have fewer problems.

"None of these rollouts goes perfectly," says Madden. "Most of the old systems, the vendors are going to work out the bugs. If you're using a new system, however clean it may be, whatever nice interface it may have, there's still going to be that lag in getting used to it. So if you're seeing four to five patients an hour, you might need to cut that down to two or three patients an hour to get used to it."

Another problem practices want to consider is that scrapping an old EHR most likely means saying goodbye to the current practice management system, too.

"If you're thinking about adding an EHR, what we see is a lot of practices giving up their old practice management system," says Madden.

In with the old

Perhaps your current EHR system looks a little retro (translation: fonts are not as bright, or the alerts don’t sound as cool) compared with newer releases. That's not a good reason to scrap it, says Madden, as an EHR’s functionality is more important than how it looks on the surface and replacing your system is more costly than replacing a two-year-old smart phone.

Also, if your EHR vendor is taking the steps to get certified, or is certified, for Stage 1 of meaningful use, and the system is easy to use and works well with your practice-management software, your practice's EHR system is probably a keeper - and ultimately, a time-saver.

"The real issue is whether or not a doc can feel comfortable staying on his older, legacy EHR," says Jonathan Bertman, a family physician who created his own EHR system, Amazing Charts, after he couldn't find an EHR that fit his needs. "I believe they can. We don't know what's going to happen with meaningful use. There's already talk about cutting this money earmarked for doctors. So that's one reality. The second reality is while [CMS is] threatening sanctions by 2015 [for not using an EHR], to upgrade to a more-expensive EHR today when the one you have works just fine for you doesn't make sense."

If a practice commits to upgrading its EHR system, it should prioritize staying current with software upgrades.

"Many vendors tend to roll these upgrades out in parcel, two to three changes a month," says Madden. "That sort of thing can be done remotely. You may be taking a half hour to an hour every month."

Another way to make the transition to meaningful use with your existing EHR easier is to take advantage of your vendor's free or low-cost EHR training programs.

"Make sure you're on the list to obtain newsletters, release notes, and documentation from your vendor," advises Keith Slater, vice president and general manager for Henry Schein MicroMD.

A number of vendors, including Henry Schein, offer free webinars or teleconferences to guide practices on updates and changes, he says. But some practices might need more hand-holding to get from point A to point Z.

For smaller practices that don't have any IT-savvy staff members, Henry Schein MicroMD offers consulting services for $125 an hour (plus travel expenses). Indeed, consultants offering help to practices getting up to speed with meaningful use abound. But most practices probably don’t need that. "A client that's well versed in the software and doing their homework could do it on their own," says Slater.

In addition to your vendor's resources, there are other resources available. Small practices may qualify for a Regional Extension Center program, where, for a nominal fee, they will receive hands-on consulting services and learn to work with their existing vendor to achieve meaningful use. Healthcare associations also offer discounted consulting services for members.

Scrapping your system

If you don't like your legacy EHR or find you can’t work well with your vendor, the stimulus dollars available now make this the best time to make a change. In fact, there are a few situations where it makes more sense for a practice to sever ties with its legacy EHR system.

The most obvious is when your vendor doesn't have future plans for the product it sold you.

"When your old vendor is 'sunsetting' the solution and offering a new one that they're going to make you buy, then it makes sense to look at other solutions," says Mark Sugrue, a director in the Health Industries Practice at consulting firm PwC. "It happens all the time."

If your vendor is difficult to work with - hard to contact, never returning e-mails or phone calls - then now is the time to ask whether a long-term relationship is in your interest.

"The vendor relationship is absolutely key," says Madden. "We've had clients who've encountered vendors who are nonresponsive. If you don't have a vendor you can rely on and trust, if there isn't that partnership that's occurring, that's obviously a red flag."

Another reason to call it quits is if your vendor's timeline for making changes and upgrades isn't in line with CMS' meaningful use timelines.

"You can qualify for Stage 1 meaningful use dollars today, but you have a limited time to get ramped up for Stage 2," says Madden. "If your vendor has no plans to work on Stage 2 within 18 months, then you're not going to qualify for those dollars."

If you're just looking for a new EHR because your existing one is cumbersome and clunky, like physician Giuseppe Marzella's, your practice can at least take heart it will get some incentive money back if it meets state and/or federal meaningful use deadlines.

"Any gap in what the physician needs and what a vendor is offering could send a practice down a different path," says Slater.

In Summary

When should you stick with your legacy system, and when is it more cost-effective to purchase something new?

• If your EHR vendor is taking the steps to get certified for Stage 1 of the government's meaningful use regulations, your practice's EHR is probably a keeper.

• When your old vendor is "sunsetting" your system, then it makes sense to look at other solutions.

• A number of vendors offer free webinars or teleconferences to guide practices on. For practices that need more hand-holding, many vendors also offer consulting services.

Marisa Torrieri is associate editor for Physicians Practice. She can be reached at marisa.torrieri@ubm.com.

This article originally appeared in the June 2011 issue of Physicians Practice.