We Bought the Wrong EMR!

The Watson Clinic started using an electronic medical record (EMR) in the late 1990s -- and couldn't wait to get rid of it.
The vendor turned out to be interested primarily in the hospital market, explains Dr. Randel Miller, a rheumatologist with the Lakeland, Fla., multispecialty practice. While paying lip service to ambulatory care, the merchant didn't really seem to care. Worse, Watson Clinic was locked into a seven-year contract, and just had to wait for it to expire.

"There was really no easy escape clause [in the contract]... . The product vegetated, and they didn't really do much in terms of expanding and improving ... . We were happy to finally be rid of them," says Miller. He has since helped the Watson Clinic form a more productive arrangement with NextGen.

The prospect of investing political and financial capital in an EMR is daunting for any physician, and the potential of making a bad choice makes it even more ominous. The "switching costs" involved in moving from EMR to EMR are relatively high. If you start with the wrong product and need to change, productivity will slow down, data may be lost, and staff and physicians will feel exhausted and frustrated - not to mention that you may lose some of the cold, hard cash you invested.

Luckily, there are some ways to reduce the risk of selecting the wrong EMR. Other practices learned them the hard way --  now you can benefit from their experience.

Don't be taken at trade shows

When it comes to picking an EMR, there are two major ways to mess up, according to Bruce Kleaveland, COO of Physician Micro Systems, a Seattle-based software provider. The first is to buy the wrong product for your practice. The second is to buy a product that is great for the practice, but then is used incorrectly. 

Chris Youseph, systems administrator at Spokane Ear, Nose, and Throat, in Washington, ran into the first sort of mistake. Physicians in his practice chose the wrong product.

As Youseph tells it, a small group of physicians went to a trade show, saw an EMR they liked, and promptly bought three licenses for the eight-physician practice. "Even before they really evaluated it, they were so impressed by it ... they just started running it."

The vendor promised that the user interaction would be easy and that data entry would be simple and customizable to any physician. However, when the physicians wanted some changes to their documentation templates, the vendor said that changes to even a single entry field would have to wait for the next software release. It was the wrong product for a practice that needed customization but couldn't provide it in-house.

In fact, not every product is as flexible as trade-show talkers might lead you to believe. "There are certain products that require a fairly sophisticated level of IT or computer competence to truly customize," says Kleaveland. "There are other products that don't have that same level of requirement that will be easier for someone with, say, basic word processing skills to master ... . Where the rubber meets the road on this is in the progress note template area." Physicians justifiably want software to match their working style, not the other way around.

Dr. Mike Arthur, for one, hated his old EMR that "was designed by computer people. It didn't flow the way you think medically. It flowed the way a computer flows." Four years ago, his practice, Coppell Family Medical Center in Coppell, Texas, spent "a couple of hundred thousand" dollars on a product from a vendor they saw as an industry leader. It was "unusable," according to Arthur.

The system did not interact with their Millbrook practice management system, and physicians couldn't make the interface work they way they thought it should. The Center eventually abandoned it altogether and went back to paper until going through the selection process again and picking a new vendor: MedicWare. It "does what you think it should do instead of having to fight the computer to practice medicine," Arthur says, adding that the new system has paid for itself in the first year, thanks to reduced staff costs and smoother collections.

Another common complaint: Software that doesn't allow multi-user access. "Physicians don't understand technology," admits Girish Kumar, vice president of sales and marketing for eClinicalWorks. They wrongly assume that using an EMR guarantees that two or more staff members can have electronic access to the same chart at the same time, eliminating the annoying waits that happen with paper charts. It may not work if you buy the wrong system. For example, Southpoint Family Practice, a 12-physician, two-location practice in Belmont, S.C., wanted nurses in both its locations to be able to pull up charts simultaneously. Luckily, it chose eClinicalWorks, which allows multi-user access.

Match the product to your needs

These are some areas to consider when you're researching EMRs:

Lab and other test results --  If you manage a lot of these, you'll want to know exactly how the vendor proposes to integrate them into the EMR. Have they built interfaces before? Will the lab data actually be part of the EMR where it can be queried or will it be a scanned-in image? Arthur worked with LabCorp and MedicWare on a cool solution: Lab results are automatically entered into the medical record. Physicians just get an e-mail letting them know the information is there. That lets Coppell Family Medical Center be a truly paperless office instead of juggling an EMR and reams of paper lab reports.

Data input -- You'll need to understand how you are going to get data into the system, particularly if you expect that some of your physicians won't embrace the EMR. At the same time, don't exaggerate input. Getting data in is only half the battle. You also need to consider how that data works in the application.

Summary sheets --  Does the face sheet or summary screen --  the front page that summarizes essential patient data --  have the information physicians in your practice need? If not, can it be changed?

Interface --  If you have existing management software, make sure the new system works with it. There are so many systems out there that you may have to be the guinea pig in an interface project, Kleaveland points out. The key is to have all the vendors committed to the outcome. "It goes to the reliability of the vendor," he says.

Involve the physicians

It will help to have as many physicians involved in the selection process as is practical. "I have seen situations where nonphysicians will procure an EMR and when they put it in front of a doctor, the doctor says, 'It doesn't do this or that.' And that's not the vendor's fault," says Kleaveland.

As Spokane Ear, Nose, and Throat learned, it also doesn't do to have a few, avant-garde physicians making all the decisions. When the practice started to look for a new vendor, "everybody sat in on it," Youseph says. That made the decision much slower than the practice's first, impulsive buy. "When everybody got involved, it got more complicated. Everybody had an opinion," Youseph admits. But it also meant the practice could charge the vendor with real-life challenges instead of hypothetical, high-level questions.

Don Trexler, executive director of Bienville Orthopedic Specialists on the Gulf Coast of Mississippi, had a similar experience. Two of the 15 physicians in the group bought and started using an EMR from a small company in 1999. It quickly became apparent that the vendor couldn't keep up with the improvements and potential the physicians wanted. The other physicians in the practice, seeing no long-term pay off, never even started using the product on a regular basis.

Trexler says that, as of 2002, the practice was still spending $31,000 a year on folders for records and $7,000 on things to stick to or in the paper charts. Between 2 percent and 3 percent of medical records were missing on any given day --  no small matter for a five-site business seeing over 1,000 patients a day.

Next time around, Trexler used his two pro-EMR physicians to start the shopping process, but involved every physician in the practice in the selection and viewing product demos at a strategic planning meeting in May 2002. When feedback was mixed, he tried again in November. Two physicians at the November meeting still didn't feel ready to proceed, so Trexler flew them and one of his "champion" physicians to tour three different practices using the system they were considering -- Amicore. They came back ready to take the next step.

The lengthy and deliberate selection process not only improved buy-in, it truly helped Trexler pick the right product. "Physicians get off the usual demo real fast," he comments, explaining that what matters to physicians is the details of their daily practice patterns.
Florida physician Miller also recommends site visits as a key way to tell if a product really does all that the marketing materials promise.

"Go to a site using [the software] in the way you want to use it. Don't be pressured by the sales force to move too fast," he warns. A case in point: One vendor sent Miller to visit a site where only one out of 100 physicians was actually using the system --  and he was forced to have technically savvy friend create his templates.
Even following up on references with a phone call can be enlightening. Arthur called the references provided by two different companies only to find that none of the practices really liked or used the products he was considering.

Know your vendor

Asking tough questions about the vendor is nearly as important as pushing for product specifics. "If you choose a company that has poor implementation services or poor technical support services or that is financially unstable, you will ... be impacted by those things," Kleaveland says. "One of the key aspects of an EMR that makes it ... a unique product ... is that the vendors end up having a very long-term relationship with the customers. These products are not easy to simply uninstall and get rid of."

Dr. John Cheng, who practices family and sports medicine in Southern California, can testify to the importance of knowing the company you are working with. His group was previously part of an IPA that received venture capital to create its own EMR. The physicians all started using the software, but a year later the money ran dry -- and so did any opportunity for improvements. "We kind of just had blind faith," Cheng says remorsefully.

The group had to switch to a more stable partner, eventually choosing AcerMed, a privately owned company that had been doing business in the billing arena long before it entered the EMR field.

Similarly, Spokane Ear, Nose, and Throat explicitly sought a vendor willing to share financial data. Its new vendor, NextGen, is publicly held, making a lot of information about the company freely available.

Your vendor should not only be financially stable, but it should have a mission focused on businesses like yours. Miller learned that lesson the hard way by starting out with a vendor that said it was interested in outpatient practices, but only invested in inpatient technology. The second time around, Miller insisted that his chosen EMR vendor have a system up and running in a group similar to his.
Mission statements, marketing materials, and even where the vendor exhibits or advertises can also provide clues to what their priorities are.

Trexler went so far as to fly to his vendor's headquarters and meet the CEO and the staff. "We wanted them to know who we are," he explains. Another benefit? He personally knows who to ask for if he has a question.

"In this industry, it makes sense to look at the real track record of the company you are buying from," says Kleaveland. "That is really the only evidence you have." Ask how long they have been in business, about the corporate focus, and how many installations they have done. "For instance," Kleaveland adds, "there may be a hot company that has sold a number of systems but they haven't scaled up their technical support and implementation services to meet the needs."

If you follow all the advice and still end up with an unusable product, consider ditching it rather than investing more time and money in a losing proposition. The good products are out there; it's just a matter of making the right match.

Pamela L. Moore, senior editor of practice management for Physicians Practice, can be reached at pmoore@physicianspractice.com.

This article originally appeared in the March 2004 issue of Physicians Practice.