Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large,
Robert A. Dowling, MD, shares the experiences of two practices that have recently embarked on the EHR transition journey and discuss the lessons they learned and how to apply them to your own situation.
The electronic health record (EHR) continues to be a dominant subject of concern and attention in medical practices today. No longer considered an innovation, the contemporary EHR is a must-have for most clinicians and often the “nerve center” of a busy urology practice.
The central influences on the development of today’s generation of EHRs were to support billing requirements (specifically documentation for evaluation and management codes) and compliance with physician incentive programs such as Meaningful Use and the Physician Quality Reporting System. As we transition into the next version of reimbursement reform-the Merit-based Incentive Payment System (MIPS)-there is even more pressure on developers and users to address legacy issues and evolve to the next generation of EHR. At the same time, many feel the EHR is the most significant contributor to physician dissatisfaction and burnout (Mayo Clin Proc 2016; 91:836-48).
In this environment of reimbursement reform, aging EHR systems, and physician dissatisfaction, we are beginning to see more urologists switching EHRs. A recent Urology Times/Medical Economics survey suggested that about 17% of respondents are considering switching, with the most common reasons being better vendor support, an ability to customize, and improved quality metrics to comply with MIPS (“EHR survey: Urologists’ usage, satisfaction revealed"). In the same survey, urologists who had already switched said they did so because of a change in their practice (such as a merger or acquisition), a desire for more customization, or another vendor-related issue.
In this article, I share the experiences of two practices that have recently embarked on the EHR transition journey and discuss the lessons they learned and how to apply them to your own situation.
Next:EHR plus PM system
EHR plus PM system
Zvi Schiffman, MD, is the president and CEO of Houston Metro Urology (HMU), a 21-physician single-specialty group in Houston. HMU had been on a urology-specific EHR for approximately 7 years when the vendor notified the practice that it would not pursue its next certification cycle (2015 CEHRT) for the EHR. According to Dr. Schiffman, the organization initially took a look at the entire large practice EHR market but quickly narrowed its choices based on word of mouth and references from existing customers.
The most important deciding factors to the practice, in addition to testimonials from customers, were the size and stability of the vendor, the ability to customize the base EHR to fit the needs of a urology practice, and the cost. After about 3 months of discovery and diligence, HMU ultimately chose athenahealth for both its practice management (PM) system and EHR.
After a visit to company headquarters, Dr. Schiffman and others were satisfied their new PM and EHR vendor met the first criteria: a healthy company with a large customer base. The fact that it was not a single-specialty product was seen as a strength more than a weakness. “We thought they would be around a while,” Dr. Schiffman said.
The EHR offered template design and customization that a physician champion could understand and perform on behalf of the other users, but individual users could also do further customization. The business model was attractive to HMU as well. According to Dr. Schiffman, athenahealth provides the EHR at minimal cost to customers in return for (fees for) revenue cycle and document imaging management at HMU. With no hardware to buy, no licensing fees, upgrades included, some staff reduction, and other economies, Dr. Schiffman estimates the net cost to switch and maintain the EHR is somewhat less than maintaining the old systems about 10 months after going live.
HMU elected not to transfer most information from the old EHR to the new EHR in a structured format, but rather created unstructured documents from office encounters, labs, etc. Medication lists in the new EHR are auto-populated from live pharmacy hubs, and clinical staff prepared charts in the new EHR manually by transferring allergies and past problems. Now almost 1 year past the go-live date, Dr. Schiffman says HMU rarely has to consult the old EHR, which remains available as a read-only source (and future data source).
The switch was easier than expected in some ways. Dr. Schiffman was impressed that the physicians’ EHR skills and literacy transferred easily, and the practice encountered no major loss of productivity. The number one lesson learned, according to Dr. Schiffman, is not to underestimate the time needed to prepare for the switch. Building templates, making decisions, transferring old information, planning, and training required more effort and time than he thought (about 5 months). In the end, HMU had a smooth transition due to hard work and preparation. The only thing he might have done differently, Dr. Schiffman said, is devote as much or more attention to training and preparation on the PM side.
2-month ‘stabilization’ period
Michael Graham, MD, is a urologist and EHR champion at Northwoods Urology, a six-physician practice in The Woodlands, TX. Like HMU, vendor circumstances brought Northwoods to a decision to change EHRs, and the practice spent about 9 months examining its options. In the end, Northwoods chose eClinicalWorks, also a company with a combined EHR/PM platform, based largely on customer references, and migrated both systems at the same time.
According to Dr. Graham, it took about 3 months of preparation prior to the go-live date, and the practice canceled elective time off for staff and providers for 3 weeks before and 3 weeks after go-live. While the practice did not trim its schedules, physicians did have to expend more energy to see the same number of patients, and it took about 2 months to “stabilize,” according to Dr. Graham. The data transfer process was not complete prior to go-live, and providers had to regularly consult the old EHR for about 3 months.
Also, lab interfaces were not redirected completely until a few weeks after go-live, leaving important information in two systems. The practice would handle these two “timing issues” differently in retrospect, Dr. Graham says.
Northwoods is pleasantly surprised by the smooth performance and integration of billing and clinical information compared to the practice’s old interfaced systems. Also, the enrollment and literacy of patients in the patient portal is easier than they imagined-something the practice partially attributes to use of the same platform and portal by referring physicians in its community. Dr. Graham says that in addition to having more data transferred prior to go-live, the only other thing they might have done differently is extend the training period. While the vendor supplied “at-the-elbow” resources before and a few weeks after go-live, Dr. Graham thinks it would have been better to have on-site resources through the stabilization period of 2-3 months after go-live. In the end, Northwoods estimates its ongoing costs are about half of maintaining the older systems.
This author also has experience with switching EHRs-almost 10 years ago (“You’ve decided to switch to a new EMR: What’s next?” Urology Times August 2009, page 40). Our organization placed the highest priority on migrating structured data from the old EHR to the new one, and this strategy generated a large return on investment by sparing the manual entry of problem lists, allergies, labs, and vital signs on every patient following go-live. We were also able to run reports and patient identification searches across the conversion date easily.
I would also stress the value of preparation, template design, customization, and careful testing (including testing of the data transfer and accuracy) prior to go-live. Every hour spent in preparation is multiple hours saved after go-live. Unlike HMU and Northwoods, many practices have overestimated the ability of a user to easily move from one EHR to another; physicians may be “locked in” to workflows or workarounds in the old EHR that inhibit their flexibility in the new one. “Just show me how I can do it like the old way” is a common refrain from providers struggling with the transition.
The absence of serious productivity decline or disruption in the two practices featured here is a testament to the preparation and training investment. The fact that both practices also successfully switched practice management systems at the same time should also offer encouragement to urologists contemplating such an undertaking.
As the EHR industry consolidates, users demand more from their EHR, and we are witnessing a shift away from simply maintaining a medical record toward a new era of health information technology-intuitive, interoperable systems with rich clinical decision mechanisms and population health to support value-based health care. As a result, more and more urology practices will face pressures to upgrade or switch their EHR.
These cases illustrate that switching EHRs is a long process that can succeed with careful diligence, planning, and training. When properly executed, it need not always involve a significant loss of productivity or massive upfront costs. Most new EHR implementations in our specialty are “replacements” at this point in time, and vendors have tuned their sales, planning, and training resources to this use case and situation.