Technology: Decisions, Decisions

In the past six months, Tony Cottone has selected and implemented a new electronic billing system for 30 clinics and 100 providers. In his spare time, he helped devise an electronic system for tracking physician orders and chose an EMR. The director of systems operations for Regional Women’s Health Management in Voorhees, N.J., says his decisions are paying off so far.

Billing is simplified, slashing days-in-accounts-receivable. The practices have much better data on what happens to claims once they leave the office. And because it’s safer for patients when physicians can be sure an ordered mammogram, Pap, or ultrasound actually happened (and that the results made it back to the patient record and were appropriately reviewed), the order-tracking convinced payers to raise payments and malpractice carriers to cut premiums.

The wireless EMR will make care even more efficient, Cottone expects: “With a tablet PC and a broadband card, physicians can stop and take a call on the turnpike and document the call right there at a rest stop. … We have fertility practices in four offices and the guys had these little wheelie suitcases they used to carry charts from one office to the other. If someone calls while the chart is in transit, you can’t help. … And in fertility, timing is everything. Having the data in real time is going to be critical to their effectiveness.”

The secret to Cottone’s technology success? Making technology decisions into business decisions.

Selecting expensive technologies can be risky. But basing the choice on business objectives keeps the focus where it should be. That sounds obvious, but, too often, physicians - like most consumers - get sidetracked by peripheral issues.

The wrong way

It’s not that physicians don’t comprehend technology. “People who think physicians make uninformed decisions don’t understand,” says Girish Kumar, president and founder of eClinical Works, who has seen plenty of physicians work through EMR selection. “Compared to other industries, these are sophisticated buyers.”

But even the most urbane shopper can get sidetracked and buy for the wrong reasons. For example, in these days of dwindling reimbursement, it’s all too easy to start a selection process by looking at price and not even bothering to really investigate the most expensive options.

“I’ve heard of people excluding systems because of price from the beginning,” Cottone observes. “You’ve got to look at the features first. You want a base idea of how they charge … but if you’re big enough to have some market clout, you can move that.” Also, it’s possible the benefits of an expensive system can more than pay for the extra costs.

The billing system Cottone picked is a good deal more expensive than the system he previously used, “but the effect on turnaround time and days-in-A/R was significant enough that it made sense to do it,” he says.

Bill Presler, senior business development manager at Panasonicin Nashville, Tenn., says some of his company’s best customers are those who used the cheapest hardware they could find when first implementing new software. When you’ve just bought a $35,000 EMR it’s easy to try to save a few pennies by running it on an inexpensive laptop. But when the laptop fails - and, Presler says, industry-wide, one out of every four machines will - and repair times stretch into months, cheaper machines can actually end up costing more than devices that are more expensive on the front end.

If an EMR selection process comes down to two products - one expensive and complex, the other cheaper and simpler - the choice shouldn’t be made on price alone, adds Rosemarie Nelson, who consults with medical practices on technology-related issues for the Medical Group Management Association. “The more robust system usually has more complexity to the implementation” as well, Nelson says. “Are you willing to put in the effort to get the most out of the product? You need to understand your timeframe.”

Conduct a reference-site visit for each product, she advises. Take along a nurse and a doctor so they can see how their work would have to change if you adopt a system that is harder to customize. If there is a lot of customization available, talk to the people who have built templates. How many iterations and how much time did it take them to get it right? Do you have the resources to do the same?

And forget brand and your image. Ask, “Are we worried about the outside world more or about inside operations?” Nelson advises. Glossy brochures and a big name mean nothing if you don’t use all those extra features you paid for.

Nelson says she often gets called in to clean up the mess created by another common mistake - slavishly following the demands of “the geek with a stethoscope,” a physician in the group who simply must have every new technology the second it’s available. “The mistake is following that physician zealot - the guy who just says, ‘If we don’t do it we’ll be dead in the water,’” Nelson says. “You feel like you have to do something because he seems to know enough about it.” Never mind that it’s not the right process or plan. “You go and you spend a lot of money and two years later you’re calling for help, saying, ‘We’ve got an EMR and we can’t make it work.’” It’s OK to listen to your geek’s advice, she adds, “but become an informed buyer. Understand what your goals are. You can’t measure return-on-investment unless you understand what you are measuring against.”

You should also hush the demands of existing vendors. It can get pretty high-pressure when you are looking into EMRs and your existing practice management vendor happens to sell one. Kumar says he’s seen vendors “camp out” until they win the deal. And Nelson says that sometimes practices feel like they have to pick an EMR from the same company because they don’t want to get into the mess of integrating two systems. She reminds physicians that even when both the management and record solutions come from the same vendor, they may not be truly integrated. Some practice management vendors bought EMR companies when they became the hot new thing and patched their software to their existing offering. It’ll work, but it’s not integrated, just interfaced.

“It’s not always a bad decision [to use the EMR solution from your practice management vendor], but it’s not always a great decision either,” Nelson summarizes. “Just don’t feel like you need to settle for second best - settle for not having functionality you want” to get an integrated system.

Also, don’t make a selection based solely on features. This is about business, not bytes. “The industry has moved heavily to a features/function orientation, a technology orientation as opposed to … looking at how a solution fits the needs of your practice,” says Dan Pollard, director of product management at Misys Healthcare. “It’s a complex buying decision, and people are looking for a shortcut.”

Initiatives to list requirements for EMRs, such as that proposed by the Certification Commission for Healthcare Information Technology (CCHIT), emphasize the functionality-based approach to shopping. That’s not all bad, but there is no sense having a bunch of functions you’ll never use or that don’t address the business problems specific to your practice.

Staying on Track

So how do you keep your eye on the business at hand when vendors, geeks, and the technology itself provide such convenient distractions?

Nelson advises kicking off every technology selection process by asking three questions that focus everyone on the real issues at hand. Here they are, written specifically for an EMR decision:

• What is your objective to be achieved with the implementation of an EMR? What problem(s) are you trying to resolve? This answer should be the key driver in the selection and implementation process, she says.

• What is your preferred solution to automating the medical record-keeping process?

• What must the EMR do/provide for you to be willing to use it?

Watch out, Nelson says, when physician partners can’t agree on the answer to the first question - or worse, when only a handful of physicians in a group bother to respond at all. “If I send out my three questions to a group of eight physicians and I only get two responses, I go back to the group and say, ‘You have a problem here,’” Nelson says.

Getting active participation and near-consensus on the core issues are key to a good purchasing decision and implementation. And that requires understanding your own business. “Identify the processes that are costing you too much money now,” Nelson suggests, instead of looking first at what processes the vendors promise to fix. Is reissuing prescriptions a nightmare in your office, or is finding charts the real problem?

“Groups seldom know their existing process costs,” Nelson says. She encourages shoppers to do a quick time-motion study or at least spell out each step in their more painful processes and estimate the costs involved.

When Cottone set out to get a clinical orders workflow solution, he started by mapping the ideal workflow, not by looking at the workflow the vendors already had in place. “We talked about the ideas and what our expectations are. We have a board of managers comprised of an owners’ group of physicians. … We worked with them to develop the specifications, what we wanted it to do. … What are the possible results for a Pap smear and, based on that, what happens? We created a workflow and laid it out for the programmers.”

For EMR selection, he created a matrix - a list of attributes any system the group selected had to have. When the physician board reviewed any product, Cottone kept them focused on the matrix.

“I wanted them to understand how to objectively look at a system. It’s hard to look at something in an hour demo and see how it would really work.” He admits it’s “difficult to get physicians to use the matrix as a tool and to stay focused on it to make sure you are getting what you want and what you need,” but the effort gets groups closer than a less structured process would.

And keeping on point is the key to success in technology.

Pamela L. Moore, PhD, is senior editor of Physicians Practice. She can be reached at pmoore@physicianspractice.com or via editor@physicianspractice.com.

This article first appeared in the May 2006 issue of Physicians Practice.