TECH: Don’t buy your PCP an EMR, Mrs Worthington

Medical Economics, a magazine doctors actually read, probably just set back the cause of getting EMRs into small practices about 10 years with this article called: Why EHRs falter (Hat-tip to KevinMD)

My take is that this needs to be an ASP business wrapped into the billing service. I think that it’s nuts for a small practice to take on the responsibility of integrating an EMR with their billing system, and even crazier for them to buy and manage software and hardware. They’re already paying somewhere between 6% and 12% of revenue for billing services, and they should be making their billing services provide them with an ASP based EMR. And quite a few out there will do that.

And think about this. My friend who is a physical therapist at Kaiser tells me that she is going to halve the number of patients she sees for six weeks and have a full-time consultant helping her individually when she gets put on the HealthConnect/Epic system.  And that’s probably the right approach. How many small practices can genuinely take that time or make that investment?

(If you’re not a Noel Coward fan and don’t understand the title reference, look here)

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  2. > I’ve seen a number of IT service companies being
    > started around supporting this small setup which
    > should be beneficial and cost effective for you.
    Which is precicely because managing a server isn’t nearly as easy as managing a desktop machine, which isn’t nearly easy enough for non-specialists to do in the first place. Which in turn is why so few desktop machines in small businesses are managed well (or at all). A small data center has nearly every problem a large one has, and I don’t think having one’s own is a good way for a small practice to go: I find it neither beneficial nor cost effective compared to hosted solutions. Once you get to a certain size (and I do not quite know what that is but I am thinking ten docs, certainly not fewer than five) then the benefits of having one’s own machines might become worth the trouble of owning them. For a soloist, I do not think so at all.
    > I think the ideal solution is a merger of a nice
    > billing system with a nice EMR system.
    Great. Go ahead and merge them. Call me when you’re done. Since billing systems are so very much easier than EMR systems, this sounds to me like a business opportunity for you.
    In my experience, vendors do not cooperate in any meaningful way. I do not want to get in the middle of this — I will be very pleased to pay an ASP to do it for me.

  3. “Because I do not want to manage my own data center.”
    Managing one server for an EMR isn’t managing a data center. Managing a server is nearly as easy as managing a desktop machine. I’ve seen a number of IT service companies being started around supporting this small setup which should be beneficial and cost effective for you.
    “Because the coupling between clinical processes and billing is getting tighter, not looser.”
    This is why an integrated EMR/PMS is such a good idea.
    “Because I want someone with a vested interest helping me understand the relationship between clinical documentation and being paid properly.”
    I think most integrated EMR/PMS have this interest as much as a billing software. Quite frankly, I’d rather have an EMR company learn and integrate billing processes than a billing company trying to learn and integrate EMR processes. Billing is much easier(Note: Easier, not Easy) to define than EMR.
    “Because I want better odds than this. Because…”
    I don’t think getting an EMR from a billing system will help these odds any. In fact, I could see them possibly being worse. If your billing system offers you a half baked EMR then you’re going to be frustrated out of your mind and want to go back to paper. As a doctor you spend most of your day doing EMR not dealing with your billing system. So, why would you want a great billing system and a crappy EMR. Once a billing system comes out with a great EMR I’d like to see it.
    I think the ideal solution is a merger of a nice billing system with a nice EMR system. Then, you have 2 seets of people working on their core competencies and can work on tight integration between the 2.
    Also, you don’t have to break the bank with $70,000+ system to do EMR. There are a lot of different pricing models that can let you get into EMR with much less risk and high quality support.

  4. Greg, your points are well-taken, and I am glad you have had a successful implementation. I would be interested to hear in what ways having an integrate PM/EMR system has made you a better doctor.
    Whether or not EMR services bundled with billing services (note that I do not say the EMR is “free”) can work depends on the vendor. If there is a billing service who wants to “Give You A Free EMR, as a Thank You Just for Using Us!” I quite agree this will be most likely a disaster. It seems to me the most straightforward thing to do for the small practice is to have EMR with implementations for a few different classes of specialty and for a couple different practice styles, and then have the practice conform to one of these “templates”.
    I have said the same thing for many years to all manner of small businessmen. Only one I can think of listened to me. He did pretty well once he realized that his ad hoc approach to doing business was costing him a great deal of money. The others have been a mixed bag, and tend to blame difficulties on the information systems rather than on their business chaotic practices. They want to continue their old habits, and computer systems are not so easy to use when the underlying processes are chaotic. These problems are emphatically not unique to medicine.

  5. My point is simply that one size does not fit all. Small practice docs are the fasting growing part of the market. Some are making mistakes by buying without enough care. As such, I think this article will make some of them think twice and make their decision with more care.
    A free EMR, whether it comes with the billing service or from CMS/VA, is not likely to work for most practices. If you think a practice is unable to, or unmotivated enough to implement a well-established EMR like NextGen, then they certainly will not be able to make a less-efficient or less customizable one like Vista or the freebies work. It takes a practice doing something similar to what your PT friend is doing in order to make a practice fit around an EMR.
    This is one of the things that has physicians nervous about the government mandating EMR use. Its feasible to think they will require specific, certified ones, and all of them being programs that slow us way down compared to whatever we’re doing now.
    By the way, as a solo FP, I implemented an integrated EMR and billing product about a year-and-a-half ago and, although it has not always been smooth, it has made me a better doctor and is working well for me.

  6. And of course I missed a perfect opportunity to point out that implementation services are transparently priced which leads customers to believe they are:
    1) too expensive, and
    2) in any case optional.

  7. > what the hell do I know!?
    Well, Matthew, you know enough to agree with me, and I know more than a little (20 years’ worth) about this stuff.
    > What are you going to do?
    Either listen to a salesman, chisel the vendor on price, turn down customizations, implementation consultants, and training training of all kinds, try to do it myself evenings and weekends because I just know I’m smart enough to do this Trivial Technical Task better than Sparky the Sales Support technician who can’t possibly understand my unique circumstances, have a project failure, and gripe forever about clueless IT types and dishonest vendors, plus everything included in the “do nothing” option;
    do nothing and gripe forever about increasing reporting requirements, about having to spend half the evening on the phone tracking down garbage that should be simply available, calling pharmacists, fighting with UR nurses, and paying an increasing fraction of my top-line for billing services. The advantage of “do nothing” is that it costs less than “have a failure”.
    But this is typical of all small businessmen, not just doctors.

  8. I agree with all of you (especially Tom and Fred) but as Doc Hinson says, what the hell do I know!?
    But think about this. You’re a small practice doc just thinking about maybe perhaps moving to put in an EMR, then you read that article. What are you going to do?

  9. Failures of this sort will continue anytime you have a system where once the product is sold, the vendor has no incentive to perform well. Enter open source, where you can fire your vendor, but keep your software.
    Fred Trotter

  10. > Why would you want your billing service
    > to offer you an EMR?
    Because these are closely related business processes that share practically all their data. Because I have already a business relationship and technical interfaces working. Because I do not have the time or the expertise to even specify “adequate programming”, much less accomplish it. Because I do not want to manage my own data center. Because the coupling between clinical processes and billing is getting tighter, not looser. Because I want someone with a vested interest helping me understand the relationship between clinical documentation and being paid properly.
    > For every failed example there
    > is a great success story.
    Because I want better odds than this. Because…

  11. Why would you want your billing service to offer you an EMR? That’s like asking your doctor to work on your teeth. I think the article gives doctors a healthy dose of reality so they can plan accordingly. EMR implementations are a challenge, but with proper planning and proper evaluation of EMR programs you can make it work great for your office. For every failed example there is a great success story.

  12. Matt, no offense, but what the hell do you know about EMR’s? This is an extremely complex industry and trying to match the right product with the right physician can be tough. And there are a lot of physicians that just buy the one that the practice down the street is using without ever seriously shopping for what would be the best fit. What works for one practice, may not work for another. And the EMR this article profiled, NextGen, is genuinely one of the better ones out there. I can point you to several practices that are successfully using it.
    Free (as in coming from a billing service) may not be good enough when it comes to an EMR. It is almost better for it to represent a significant investment, because the physician then is more likely to feel invested in the training as well. Though there are often other safety and efficiency benefits, an EMR WILL slow down a physician when it comes to charting (compared to paper alone or dictation)free . Just having some crappy product handed to you is very unlikely to work. If the EMR was adequately programmed, it would not be free, as these things represent a significant amount of work and investment just to create. Medicare has just made the VA system, called VISTA, available for free to everyone, and they cannot find any takers because it is not a product that will help us to efficiently chart our notes when we see patients.

  13. I just read the EMR article in Medical Economics. I am in total despair because this might be considered a positive view of the state of EMR adoption!
    Our billing service, Preferred Health Resouces, offers our Practice Management service, including scheduling, with personal training, and most doctors don’t bother to signup, let alone ask for full EMR. Oh, by the way, it comes free with the billing service. They would rather just put their paperwork in an Airborne package and have us deal with the problem.
    I have seen everything the article talks about. Only some of the doctors using the system so the practice is still stuck with paper records. Doctors leaving a practice because they are the ones pushing for a modern system. Doctors always having problems with IT vendors, and we clean up the mess. ERM systems that make template implimentation too difficult.
    System integration, a total nightmare. We offer a Palm/PDA charge capture program. We haven’t been able to get a single hospital to give us access to demographics so a doctor doesn’t have fill this basic information in. When it somes to standardss the bottom line, HL7 is mainly a EDI standard, not an modern Internet standard, as implemented by most vendors.
    I would give our PDA program away if I thought it would help, it won’t.

  14. Yes, I think you’re right about the hosting model for the small practice: not even an Englishman would be mad enough to bring these ugly ducklings in house. It is difficult enough to use them properly, much less manage them.
    As for the six week implementation cycle, what does anyone expect? I don’t think going the ASP route will help very much with this — it doesn’t take but a day or two to prepare hardware. It is getting the data sorted-out and loaded that takes the time, and that wouldn’t change a bit.
    But I don’t think your friend can afford not to do the project. Returns to IT are increasing in healthcare…