Why Small Practices Resist EMR Implementation

There are many reasons why small practices have not implemented electronic health record systems to date. The thought of completely changing the workflow of a practice is scary. Change is intimidating and for many, something that just doesn’t need to happen right now. Cost still is and has been a major hurdle in implementing electronic health record systems (EHR) for most small practices. Upfront costs can be staggering to a small practice already burdened with high insurance and overhead. The perceived return on investment (ROI) just doesn’t justify the expenditure. Software, training, IT equipment, and costs to convert paper to data all add up to keep providers from making the leap. One of the most important costs is not a direct expense. It’s the cost in lost revenue due to workflow disruption that serves as a major impediment for many small practices. This is especially true at the provider level.

Provider acceptance is one of the other major roadblocks to successfully implementing EHR and also has historically caused many practices to delay its purchase. Many providers have been doing things one way for years and are reluctant to change. Others don’t feel comfortable with computers and are intimidated by the thought of computerized provider order entry (CPOE). Some providers just don’t believe in the new system and can’t find a good reason to support it. This is especially a problem when there are only a few providers in a practice. If one provider with influence doesn’t like something, that sentiment is sure to spread.

Staff buy-in has been one of the main stumbling blocks for failed EMR implementations. Practices who believe they can train on their own have a high rate of failure. Lack of planning and failure to emphasize pre-training is a huge mistake that can be avoided. Practices that don’t spend enough time communicating with their staff and getting buy-in from their providers are at risk of spending thousands of dollars only to have workflow seriously interrupted to the point of going back to doing things the old way. I watched a rural clinic spend $2 million on a system that wasn’t right for them only to start over as staff rejected it. So how do small practices get past these obstacles?

Through financing and stimulus money, small practices can now get to EHR without going broke. If you are in the healthcare industry, you’ve probably heard about the American Recovery and Reinvestment Act of 2009 (ARRA) promising to distribute $787 billion. The HITECH Act is a $19.2 Billion component of ARRA intended to increase the use of EHR by physicians and hospitals. The money will be distributed through reimbursements after showing “meaningful use” by the practice or hospital. This windfall of federal stimulus dollars is also coupled with future penalties of reduced Medicare payments to providers who fail to adopt EHR starting in 2014. Apparently, the government believes that a combination of incentives and penalties will induce physicians to start adopting EHR’s sooner than later. According to Dan Murray of Integreat (igreat.com), over the last couple of years it’s been a slow process with many small practices saying “I’m not quite ready yet.” But, with the incentives starting in 2011, he says his phone is ringing off the hook.

Since the government is promising reimbursement, that’s not the same as a grant. Doesn’t that leave small providers still responsible to come up with the money? Yes and at the same time, a Big NO! Many vendors and consultants are assisting with financing and deferred payments so physicians do not have to pay until they receive their government reimbursement. The trick is to find the right vendor and/or right consultant who can help you find the best solution for your practice and your financial situation. Where a practice may slip up is choosing an EHR that doesn’t guarantee meaningful use. I advise looking at EHR software that is either certified or pursuing certification. This puts some of the smaller EHR and free EHR vendors at a disadvantage, but it is a safer play for a practice that doesn’t want to be strapped with repaying a loan because of failing to meet the “meaningful use” standards. The other thing you should understand is the difference between vendor responsibilities and your responsibilities when it comes to guarantees. Just because the vendor software is capable of meeting meaningful use criteria doesn’t mean the staff is using it to its fullest abilities. Qualifying for stimulus money rests firmly on the back of the practice.

“Meaningful Use” is a term that most people in the healthcare industry are still trying to understand. How will it be paid? Exactly what is required? The Certification Commission for Health Information Technology (CCHIT) has updated its certification criteria so a pretty clear picture is now available.

The Interim Final Rule has been issued on meaningful use, and the final rule is currently in the public comment period. So, the final requirements should be out hopefully by mid 2010 and shouldn’t change much at this point. If you are a small practice, and you aren’t tech savvy, don’t rely on your vendor to tell you they meet meaningful use criteria. Go through the matrix checklist and ask them how their software handles each of the qualifying capabilities or have your Health IT consulting firm ask those questions for you.

So, now that you have the money issues solved, let’s get an EHR, right? Not so fast. You could easily pay much more than the $44,000 per physician over a four year period the government is promising depending on the size of your practice. Vendors have different pricing structures to look at. Some are Server/Client based where you host the data and the software. These tend to have large licensing fees and expensive upfront hardware costs. The advantage is you are in control of your patient records. The other big plus to this setup is when the Internet goes down, you’re still up.

Another option provided by many vendors is the software as a service (SaaS) model. With this approach, you pay smaller upfront fees but pay for the use of the software each month. This is a way for many small practices to implement EHR without going over the allotted stimulus money. However, the downside of this approach is a continuing cost for the lifetime use of the product that the initial license buyers don’t have. You really have to look at the total cost of ownership (TCO) when making your decision.

As a small practice with limited resources, purchasing an EHR as a monthly service is a great way to save money initially. I personally prefer the server/client method, but this usually requires a dedicated IT staff that can be more expensive than the monthly service fee. If you choose an IT vendor who can manage your IT needs remotely (most of the time), the cost is very affordable.

Now that you have the money issues handled, let’s discuss staff buy-in and training. I can’t emphasize enough how important it is to get everyone onboard and committed to the new system. Prior training and workflow analysis can make the transition easy. Lack of training and buy-in by providers and staff will not only make the transition difficult, it could actually sink the project. There are some key steps to getting staff buy-in and they include appointing a project manager and a project champion. As a small practice, you may want to hire an outside IT consulting firm as your project manager or have your in-house project manager work closely with the consulting firm to assist in choosing a vendor. You should also identify a project “champion” in your provider group to continuously lobby for buy-in by his/her peer group. There are many more important steps and a good IT consultant with a solid vendor will provide you with a road map to success. It is then up to you to follow that map.

There are many aspects to consider when implementing an EHR, but as I stated before, training your staff is a key ingredient to a successful migration. One thing you should evaluate is the current computer knowledge of your staff and providers. It is very important to get those who are at a very low ability up to an acceptable level prior to receiving training on the new system from your vendor. Some practices try to save money by passing on formal training and choose to only utilize online training provided by the vendor. This is a huge mistake. If anything, you should err on the side of over training. Some practices implement EHR one component at a time and take baby steps. This is a really good approach for them, but it may not be a good approach for you.

What is changing today is time is running out on the stimulus money. If you are not ePrescribing already, you are about to lose out on a 2% reimbursement from Medicare. By 2011, you will only receive a 1% incentive and if you aren’t ePrescribing by 2014, you will be losing 2%. Waiting to fully implement your EHR could be costly. This decision should be carefully measured prior to going live on any component of EHR. So, the choice is yours. You can collect your share of the incentives or pay your share of the penalties.

Today, small practices have the best opportunity they may ever have to implement EHR with government assistance. But, it is time to get serious and pull the trigger due to some serious logistics issues with EHR vendors. The move to EHR is happening right now, but the big rush hasn’t quite hit yet. Experts are predicting big backlogs and long lines for implementation by next year. If you are late to the game, you could miss out on funding due to anticipated vendor backlog. You may end up with an EHR or practice management (PM) solution that isn’t your first choice because the one you want can’t get you on schedule. It’s kind of like settling for the car the dealer has in stock instead of the color and trim you want. Only this is much worse. Experts are also predicting a shortage of qualified health IT professionals during the next several years due to the government incentive program. So, now is the time to get serious and let the government pay for your EHR. Just don’t wait too long.

For more information on Electronic Medical Records and for assistance, go to www.technologymanagementpros.com

EHR Implementation