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HIStalk Guest Writer: Jonathan Bush and Getting Small Groups to use EMRs…with no Cash Promise

July 23, 2008 News 26 Comments

I met Jonathan Bush right after the HIStalk/Healthia cocktail party at this year’s HIMSS conference.  As a HISsie winner in every category he or his company was nominated, athenahealth CEO, President, and co-founder Jonathan Bush was gracious enough to receive his honors in person and then entertain the crowd with his commentaries on HIMSS, the industry, and boat shows.  After the festivities, I went to whisper in his ear that I was "Inga" and he thought I was trying to give him a peck on the cheek.  Of course in return he gave me a little air kiss – and then a big laugh when he realized I was just trying to tell him my secret (it was so very cute.) 

Besides being cute, Jonathan has proved to be an innovative and successful leader, leading his company to last year’s most successful IPO. And he is big HIStalk fan (I think he and Mr. H are tight.)  We appreciate and thank him for taking the time to share his wit and wisdom with other HIStalk readers!

– Inga

About 50% of doctors practice medicine in small groups. The vast majority of them don’t use EMRs. Why not?

For the past 5 years, we have seen a huge uptick in the buzz around the adoption of EMRs and what it will mean for healthcare. EMR software companies issue press releases on new functionality or new versions and the prospect of a paperless delivery system. With all this innovation by software companies, and HIT conferences popping up every month to discuss "interoperability" and "standards," why on earth haven’t more doctors in small groups adopted EMRs?

Better yet, why do the small-doc practices that have EMRs resist using them to their fullest advantage?

The other day I was on the phone with a Wall Street Journal technology reporter, discussing the lack of adoption of EMRs by physicians practicing in small groups. I was glad this got the attention of a journalist who doesn’t normally cover healthcare. A little over 8% of 1-3 doctor practices have some kind of EMR…and the actual usage of "fully functional" EMR technology stands under 5% (data from MGH’s Institute for Health Policy). Earlier, more optimistic estimates were closer to 15-20%, but so far, no go.

The problem is, EMRs are usually tools, not services, I explained. If they were services that docs could use properly while increasing cash flow, they’d be flying off the shelf.

So the journalist asked a reasonable question: How much cash flow does athenahealth’s EMR service provide for physicians?

And I had a totally unreasonable answer: "Uh…"

The fact is, I don’t know! Here’s what I do know: Our EMR increases cash flow by removing paper from the process. Unlike old school EMRs, our athenaClinicals service handles all of the documents that enter our clients’ office as part of the service.  So far, that’s more than 60 documents every day per FTE physician — 68% of which would have to be handled manually by the client. This means that even if they had traditional EMR tools, our clients would still be handling a large portion of their documents manually. But how much was it costing them to handle those manual documents before they got onto the athenahealth network?? Not the foggiest clue. What about if they got some consultant or custom programmer to build a bunch of interfaces and maintain them every time something changed at the lab?  Not sure, but it sounds ugly and expensive to me.

What’s the solution? Actually, I’m not sure. What do you guys think? Invest in a time study? Wait for real P4P payments to kick in before the REAL docs out in the community adopt or let the academics with endowments lead the adoption wave?

So I will stop my post here, because one of the core reasons I like Mr. HISTalk, Inga and this blog so much is that it has emerged as a disruptive presence in how folks in our industry get their news and discuss topics and trends.  So let’s discuss this…maybe we can get an actual dialogue started here that will begin to disrupt our industry’s stagnant approach to the small physician market.

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Currently there are "26 comments" on this Article:

  1. While the comments were charming, I found it very disconcerting that the discussion focused entirely on the financial returns to the EMR — with not a word about patient safety, quality of medical service, quality of the EMR interface for clinical practice, or the ease of use by physicians. I would suggest that if a fine, intuitive and useful EMR were offered, more physicians would flock to it.

  2. You said some interesting things today. I started working with EMRs back in 1994 and have heard just about every possible pitch to doctors (and made quite a few of them myself) about the significant value inherent in an EMR. There have been several studies that have attempted to discover why small practices aren’t having the docs get a second on their mortgage and buy into the the brave new world. The best way to understand this is to take off your geek hat (I am a geek so I have to take my hat off too) and look at the problem from the perspective of a non-geeky doctor.

    Here’s the first hurdle. You call some buddies, talk to the hot new doc next door who plays video games during lunch and ask them which system are they using. Your buddies look at you and say the same one I’ve been using for the last 30 years – paper. The cool doc next door invites you over for a session of WarCraft and shows you his server room, touch screen computers and tells you about the wireless access points he has all over the practice. He then gives you the industry scoop on XP versus Vista and warns you to wait for a while before you move your system onto Vista. Needs a couple more updates. You trot back to your office just in time for the afternoon patients that will be arriving every 10 minutes. And you see on your schedule that Mrs Kruftla who will take up 30 minutes telling you about every ache, pain, and imagined disease and will fill you in on all of the goings on with her friends . There’s 30 minutes right there.

    Physicians are dealing with some significant hits to their bottom line. That means either put the kids in braces or try and figure out how to pony up the big bucks for an EMR. Regardless of the model (ASP, local server etc.) don’t forget about the cost of the installation and hardware or the support costs and the inevitable hardware upgrade. Not a chunk of change the docs have laying around right now.

    Once you have the EMR purchased and have paid the big bill for the implementation and the hardware you have to figure out who in the practice is going to be the “computer person”. Not an easy decision since in small practices they don’t have a large pool of people to pick from and they don’t have anyone who “does” computers. They are just as illiterate as the doc. So how do you get your part of the install done?

    Given that you don’t know much about computers (maybe not your generation — maybe you just don’t care) making a bunch of decisions about hardware — dedicated data lines, back ups, scanners, interfaces (and on and on and on) isn’t in your comfort zone. Given the lack of cash floating around in your piggy bank you would be foolish to undertake such a big project yourself — if you had the time (remember your Medicare payment cuts so you have to work a lot harder for those braces for the kids and oh, I don’t know, maybe sending at least one of them to college).

    But lets say you put on your big girl panties and go for it. Jump right into the mix. Damn the mortgage I need one of those computers with the access somethings and for sure make sure I get the exlax one and not the Vistaril machine that will — ah make you go to sleep I think… (doctor and nurse humor).

    So you made it. You’ve got this new, new computer up and running and you walk into to see your first patient — here you go —

    Well there is a little problem. Nothing is working. Maryann, the designated computer person is wandering around the practice with a fith of bourbon and the waiting room is full. Time to — you got it, pull out the paper records.

    You make the call, the vendor tells you — on one small problem. Your access point needed to be reset. Not a big deal. Tell Maryann to get on a chair and open the panel in the ceiling and press the red button (what? no red button) oh yeah you have the Z-7900 model no red button its a green one on the top…

    So tell me what physician in their right mind would buy into that.

    Cost and reoccurring cost
    Lack of expertise to make an intelligent decision
    Cost and reoccurring cost

    There have been many attempts to solve these problems. The problem is if you are really going to solve these problems as a vendor you are looking at some very slim margins until your clientele get settled in.

    Years and years ago I was tasked with developing one of the first electronic health records (we called them CPRs back then). I had a group of physicians from various clients come in and look at the nifty stuff we had done. I was going to introduce them to the world of the GUI etc.

    But throughout the meeting as much as I tried to get them to tell me what they thought I got nothing. Tthey listened politely, ate the food we brought in and met us for dinner at a swanky restaurant. I finally asked one of the docs why there was so little excitement about this new, new thing that was going to revolutionize health care. He summed it up very well. All I have to do is ask and someone will get me the information. How much simpler could it be than that?

  3. I think the question doctors need to be asking is “If my staff didn’t need to spend time doing X, what could I be doing instead?”

    Lets say it takes a staff member 3 hours to go through those 60 fax’s a day /FTE. What could that person do if they were given those 3 hours back?

    Could they more aggressively go after self-pay balances?
    Could they leverage the reporting in your EMR to ensure they are seeing 100% of their diabetic patients for their foot exams, and if not, proactively contact them?
    Could they spend more time negotiating contracts with payers?
    Could they spend more time marketing to increase the number of new patient visits?


    Any of those items will increase the practices cash flow.

    The only problem I see with asking “If my staff didn’t need to spend time doing X, what could I be doing instead?” is that software doesn’t necessarily give you that 3 hours back. For some practices it might, for others it will take more time.

    With the flurry of software available to doctors to go electronic, how is he/she supposed to know which will actually give them that 3 hours back vs taking more away?

  4. The reality is that it doesn’t matter how much a physician cares about patient safety if they can’t afford to keep the doors open and pay their staff. Primary care physicians have dissappeared because it is no longer a financially viable business. Until the reimbursement structure is radically altered I doubt we will see any significant change in medical practice or truely successful EHR or medical home implementations. I have practices primary care Internal medicine in the rural adirondacks of upstate NY for over 15 years and canpt afford the cost of implementation with all the data feeds and connectivitty tthat a successfulEHR requires. In New York State the Department of Health has a major initiative underway to get RHIO connectivity and work flow implementation support out to small practices throughout the state but we still don’t have the financial reimburement issues solved so it is a very long and slow process.

  5. There are multiple dimensions to this – but I have no doubt that cashflow was , is and will remain priority #1 for a small practice . I would be interested to learn from Jonathan what Athena’s own experience is regarding EMR adoption in its customer base . After all , ATHN introduced EMR not so long ago , on top of the revenue service and I would expect some customer feedback .
    From what I know , most EMR’s – service or not – are configured as ”one size fits all”. That does not fly – even with those small practices which generate premium revenue ( Orthoped/Cardiology,etc ). Many of those docs work in private practice as well as various hospitals….on the same patient.They need their ”own” clinical specialty EMR , irrespective of location or other pieces of the IT jigsawpuzzle

  6. Internally I chuckle out of despair when walking down the hall of a high profile medical center and see the practice of writing SOAP note components and lab results on paper towels. SOAP notes and clinical findings are part of the Medical Record so why is there a perceived fear factor “Electronic” in the EMR? Maybe CCHIT paper towels could be an inexpensive alternative to EMR for small group practices.

  7. I’m old as the hills and got started working on EMRs back in the early 1970’s when I was in academics. Back then it was all about improving the quality of patient care.

    Realistically, however, things have changed substantially over the past thirty years. Physicians, particularly in small practices and/or where procedures are not a major part of their income, are necessarily very concerned about their financial situation.

    After 30 years in industry I’ve recently gotten back to teaching. After several months of working on an EMR presentation I started giving two things seem very clear to me:

    1) In most circumstances the substantial majority of the return on the investment in an EMR accrues not to the practice but to whoever is financialy at risk for the patient. The ratio is probably close to the Pareto rule — 80/20 in favor of the payers.

    2) The payback that does accrue to the practice, as Jonathan suggests, is mostly, if not entirely, the result of workflow and process improvements.

    IF we are going to have universal adoption of EMRs in this country then one of two things needs to happen:

    1) The Federal government needs to do what the governments of Australia, NZ, the UK and others have done — establish a system of financial incentives that pays for EMRs. It’s already taking the first “baby steps” in this direction: the EHR pilot program just announced and the new Medicare law that provides a 2% incentive for e-Presecribing. Obama’s plank actually calls for $10Billion per year for five years — enough to almost exactly do the job if my math is correct.

    2) The vendor community needs to recognize that the ROI for MDs is based on workflow and process improvement and work much harder on that than in the past. Harder, in this case, means not only product improvment but improved training, consultation, etc. so that physicians actually get the needed results.

  8. As an EMR vendor catering to primarily small practices, we have learned some lessions in this business.

    The dirty secret of the EMR industry is the number of failed installs. Physicians know it is no secret because they have colleagues with failed or marginal installs. Fear of failure after a big outlay of cash is a concern…but there is another factor.

    We have turnstile pricing (pay per new pt encounter) with no upfront cost for the software. Our software is affordable. All of our customers are paperless. We have HL7 interfaces to labs and PMS companies. We have on-the-fly edits to templates. It is client-server with a Microsoft SQL backend. The fax machine connects to Medtuity. Our software is not run-of-the-mill.

    So what have we learned as a vendor that allows an affordable paperless EMR? To never discount the human factor, especially in the small office.
    First, contrast the small office with the large, multi-practitioner office. The small office often has a family member (perhaps a mother-in-law or sister) “in charge”. You can’t fire your mother-in-law. If that person does not want an EMR, the installation will fail.

    In the large office setting, such a recalcitrant employee would be given a pink slip in a cardiologist’s heart beat.

    As recently as yesterday, a physician called to say that they were re-instituting Medtuity after firing their head nurse. She nixed their first try before they could even attempt a go-live date.

    An important aspect of this phenomenon is the fear of “loss of power”. The employee has a sweet job, not too much pressure, and not too many skills. The fear, I believe, is that the EMR will put power into other’s hands.

    Don’t underestimate the human factor.

  9. Biggest problem with EMR ROI’s is the calculation.

    Most people will go through and say “Oh I can save 10 percent of one persons time here, and 25 % of another persons time here.” All the time saved each person is redirected towards actions that generating revenue.

    However in all actuality partial FTE time savings disappear into the ether. If you think about 10% time savings is only 6 minutes per hour, and 25% time savings savings is 15 minutes per hour. That is such a small time in a busy schedule. How is someone going to go re-task and complete they new action in 6-15 minutes.

    Unless you can fire of one full FTE, and then hire a new FTE with the skill set to help with the revenue generation tasks, returns are never realized.

    In deed the human factor is very messy for EMRs.

  10. I have worked in this industry since the early 80’s. I have been involved in the entire business process; design, development, implementation, sales, and support. My company is one of the largest providers of POMIS/EMR/EHR/EDI solutions in this industry today. We are arguably the very largest in terms of providing services/tools to small practices, specialists, and HL7 clients. Having this experience, I think, qualifies the following statements.

    The reason that more doctors do not implement electronic solutions is quite simple; cost and the inability to accurately define cost savings. It is an intangible asset and in some circumstances it is quite possible that they could lose more than they gain.

    Outside of the upfront cost for implementation (which is substantial) there is the additional *recurring* cost of needing an IT person, support, maintenance, and training for staff. This is not easily defined and can vary year to year (even month to month).

    The fact that in a normal workday, the only “benefit” the doctor will see (or even cares about) is cost savings and improved revenue means that until this can be made completely tangible (prior to implementation), there will be no widespread adoption and/or exponential growth of emerging technologies. In the end, all the doctor/practice really cares about is getting their claims paid and paid promptly. There is quite literally no substitute for a good billing person. That is the best investment that any doctor could make (even today).

    Having said all this, how did we become one of the largest distributors of POMIS/EMR/HER/EDI solutions? For one, we have, arguably, some of the greatest minds and guru’s in the world (always invest in people). Our sales teams ain’t bad either. In the end, the core reason for our success today has come from early adoption during an era (80’s) that was a prime environment for our type of software (this era was a prime environment for many reasons outside the scope of this commentary). This early adoption, and our ability to provide quality software tools/services, has laid the foundation for any success we see today and our continued success tomorrow.

  11. Financial Number Cruncher:
    While ROI is important, the aggravation index is as well. If you eek out an ROI but your aggravation is increased, forcing you to take off the entire day on Friday, not your usual half day, then what ROI is that!

    ROI is overrated, (and I think that is what you are saying). Should a doc pick an EMR with a 12% ROI over one with a 0% ROI?

    In fact, the focus should be the aggravation index. There are plenty of physicians who love the field of medicine, but dislike many of the aggravations of its practice.

    My impression of AnethaHealth is “We’ll take care of the aggravating stuff” and docs are buying off on it. Maybe it will give a doc 10 years more tread life to practice medicine.

  12. Ross Koppel said: “I found it very disconcerting that the discussion focused entirely on the financial returns to the EMR — with not a word about patient safety, quality of medical service, quality of the EMR interface for clinical practice, or the ease of use by physicians.”

    When I started working on my first EHR project I was positive that I could design and market a system that would focus on improved care for patients. I was really surprised when I started talking to some early adopters of the technology to find out that they thought their quality of care was pretty good. When you look at it from the perspective of a provider they usually don’t think their care is not of high quality so when I was talk about having a dashboard that would let the provider see medications, problems, notes, and preventative health screenings I usually got few docs out of the group who focused on that.

    I always connected with providers when I talked about lost charges, reducing clinicl staff, less time running around looking for charts, electronic prescriptions, etc. One doc told me that if he couldn’t keep the doors open then the quality of care issue was moot.

    As far as ROIs are concerned – yes they made a difference but they need to make a big difference. One vendor that I have seen a demo from recently told my clients and I that the ROI was hige and that they system would pay for itself in 18 months. When we asked to see the details he showed us how we could get ride of paper records thus recoping the portion of our office space dedictaed to file cabinets.

    We heard how we could get rid of staff and eliminate a position. Not something that small practices do. Big practices — sure. Less familiarity with the people working at the clinic than if you are a 5 man practice and have had the same nurse, receptionist and medical assistant for the last 20 years.

    The best ROI is found in billing systems which are proving their ROIs. Clinical systems in most cases are not well connected with the billing system. Many practices don’t want to make a switch and risk a financial hiccup in changing billing. In small practices a hiccup can be devastating.

    Last week I was working with a group of cardiologists who are thinking about how an EMR could fit into their practice. The first goal — that the EHR not put them under financially.

    Interesting dicussion on this topic. Logical conclusions but apparntly they are falling on deaf ears. The proof is in the lack of adoption.

  13. I’ve been working with small practices implementing EHRs since I was 21, and the one thing I’ve learned is that until a physician can see that there are tangible financial returns, there’s always a reason to not go electronic. Unless of course they just want a new toy.

    Reasons not to use an EHR:
    #1: “I’m waiting to see what the hospital is going to do.” With the relaxation in Stark, everyone thinks it makes sense to wait for their local hospital to offer an EHR for free. When it really comes down to it, most hospitals aren’t prepared to do a stark offering. They’re still trying to figure out their inpatient EHR.

    #2: “I don’t have enough money for it.” Primary care is in rough shape…but maybe that extra 2% from Medicare will make them feel better….probably not.

    #3: “The ROI hasn’t really been proven.” Well, in some cases it’s easy. You say you spend $60k/ year on transcription and it still looks like a mix of English and Indian once it comes back in a week? Easy…let’s get you to use Dragon. and I’ve just saved your practice enough to buy an MRI in five years. The reality is, most small practices are like a family. They don’t want to let someone go just to save money, but reducing your FTEs by attrition doesn’t hurt anyone’s feelings.

  14. mchasemd,

    you and I are on the same page. ROI is an overused term in Healthcare. There are way to many variables in this industry to get a good ROI. EMR’s overall will not have a positive ROI, or even IRR (Lets see the Marketing Guys use that one now) in the current environment. Cost of support and installation is way too high, not enough standardization, too much training etc.

    Like I learned way back when…. the lowest hanging fruit is rarely the shiniest. It is easier and more rewarding to go grab that low hanging fruit standing on the ground, then to go buy a fancy ladder to get to the fruit on the top. Because once you own that ladder your going to have to carry it.

  15. Anonymous

    “#3: “The ROI hasn’t really been proven.” Well, in some cases it’s easy. You say you spend $60k/ year on transcription and it still looks like a mix of English and Indian once it comes back in a week? Easy…let’s get you to use Dragon. and I’ve just saved your practice enough to buy an MRI in five years. The reality is, most small practices are like a family. They don’t want to let someone go just to save money, but reducing your FTEs by attrition doesn’t hurt anyone’s feelings.”

    If that was true, you would see more people flocking to EMRs. The reality is most EMRs do not swap out the transcription costs with a 0. You have a cost for the EMR, you now have a cost to get the EMR to interface with Billing, you have an entire list of costs that increased. We(corporate America) would like to think that the everyday person is more emotional then we are, but it is not true. This segment of America is not overly emotional and dollar dumb segment. They have to have some business sense to be in business. they do might lack the capital resources that we own, but it does not mean they are emotional.

  16. I think financial return is necessary but not sufficient. This is because it has to be prefaced (in bold) as POTENTIAL financial return. All doctors have colleagues who have gone through a botched or difficult EMR implementation and suffered because of it. Many doctors have also either used an EMR or seen one in use, and the reality is that most of them are not that easy to use/customize/learn. That means that an EMR purchase means to a doctor: it’s going to get worse before it gets better, it may never get better, and if it doesn’t get better I’m going to be out a lot of money.

    That means we need to change the equation. We need to make the systems look and function “not so bad” so that doctors don’t think life is going to get worse if they go with one. This means not just usability, but reliability and performance. We need to get rid of the POTENTIAL part of the return and make it almost 100%, guaranteed except in a disastrous set of circumstances that normally don’t happen. And we need to reduce the potential for loss to something that most doctors can tolerate. Most small practices could tolerate the cost of a few low-end computers, networking, and a small upfront fee or monthly cost. They can’t tolerate interface fees or tens of thousands in license fees, plus 6 months of contacting and all the other crap that larger groups can absorb.

    There’s some interesting work in the diffusion of innovation field that suggests we’re stuck in a gap between the early adopters and the early majority (right at about 12%). The suggestion is that the people who see the above equation in a positive way have already adopted, and the next big group have yet to have it proven to them that this is worthwhile. Short of some significant changes in the equation, this is going to take a while…

  17. Re. Getting Small Physician Groups to use EMR. I have a question related to this topic. If I thought of it most certainly has been thought of but since I don’t know the answer I won’t know the answer until I know! Right? Has any vendor considered attempting to approach the problem of small physician practices adoption with a system that a larger group, say a co-op or a consortuim, could purchase? There would be challenges in this approach, too, however, I would imagine that it might allow the price per user or per practice to be more manageable. Thoughts?

  18. DrM,

    I agree wholeheartedly with you…but there are no guarantees. I think the closest might be an EMR where physicians could easily trade content (templates, “clinical store” items, form letters, forms, codes that are tied to clinical content (the CPTs, LOINC, NDCs), , etc.

    At least if you know that your friend the endocrinologist on the other side of town (or the US) is successful with his EMR, and you have a similar practice, and can trade content easily, that the hurdle is lower.

    While we have added the ability to even email templates to a colleague, it does take some time to generate enough traction. Let’s say there are 5,000 rheumatologists in the US and 12% have adopted, but spread over hundreds of EMRs (most of which do not allow easy editing of the clinical content), then the traction is not yet there.

    I disagree with the notion that there should be separate EMRs for separate specialties. There are too few docs in many specialties and thus the financial incentive to a company is lost.

    It is better to have an EMR engine that easily allows content changes, additions, and deletions across the spectrum of clinical content, templates, forms and more. Allow the EMR to be “specialized” and content traded.

  19. Getting back to the original question of Jonathan’s – basically, where’s the money, here’s my view:

    As others have stated, it doesn’t exist for small practices (1-5, maybe even 10 physicians). The potential % FTE workflow savings is nominal, sure you might free up some space in the office, but not that much.

    Practices with 10-25 physicians will likely see sufficient savings, overtime, that justify the investment, provided they have someone on staff that is tech savvy and thus will not require a lot of training.

    Practices with more than 25 physicians, it’s a no-brainer, savings will accrue . Though with any of the above, the common metric I’ve heard bantered about is that you are going to take at least a 6 month hit in productivity – something most small practices can ill-afford.

    In all cases, the payer will see the greatest benefit.

    Get payers to foot the bill for small practices. How about a sliding scale with full subsidy for very small practices, partial subsidy for mid-size and let the larger practices foot their own bill. Regency sponsored EMR deployment in a town out in OR, average annual cost was $3000/physician, not all that much. One of the big findings was the need to really spend time upfront to get people trained on the EMR (DUH!). They considered the program a success.

    Hosted (SaaS) solutions will be ideal for smaller practices as they eliminate onsite IT support. All you need is a computer.

    Costs are coming down for EMR systems and they are getting better, more intuitive (early versions were horrible, no wonder adoption was low)

    Longer term:
    It will be imperative that doctors move to a digital modality as their customers will increasingly expect such out of them. Customers will want online refills of their meds, making or rescheduling appointments, access to their labs and records, all online. Those that do not will find their ability to attract new customers waning and those that do offer such services by leveraging their EMR will see the opposite.

    Far too often people talk about ROI – which is BS. What the real focus needs to be is on value delivered and the value proposition really depends on what kind of practice the physician(s) wish to run and what type of customers that practice intends to serve. Once they figure that out, then they can begin a discussion on what is truly valuable to their practice.

  20. Re: finance number cruncher

    “If that was true, you would see more people flocking to EMRs. The reality is most EMRs do not swap out the transcription costs with a 0. You have a cost for the EMR, you now have a cost to get the EMR to interface with Billing, you have an entire list of costs that increased. We(corporate America) would like to think that the everyday person is more emotional then we are, but it is not true. This segment of America is not overly emotional and dollar dumb segment. They have to have some business sense to be in business. they do might lack the capital resources that we own, but it does not mean they are emotional.”

    I was obviously oversimplifying the $60k ROI to prove a point, but in the end, yes there are two doctor practices no longer paying a cent for transcription that once cost them an arm and a leg. There are costs for the EHR, but they broke even after 6 months. Sure, not every doc pays for a ton of transcription.

    From the emotional perspective, I’m really not sure what you’re trying to say but to assume that physicians have an abundance of business sense is a little presumptuous. Maybe the readers at HIStalk have a high business IQ, but the hundreds of physicians I’ve worked with in small practice admittedly don’t know much about business at all. In medical school, how many business classes do you think are offered? Not many that I’ve seen. That’s why you still see physicians UNDER-coding to make a visit more affordable for a patient even if the allowed amount on that visit would cover even more than their 3 year old fee schedule shows. Don’t underestimate how much emotion physicians put into their work. Many times they care about their patients and their staff more than they care to take home an extra $20k/year.

  21. Quilmes Boy Said “I have a question related to this topic. If I thought of it most certainly has been thought of but since I don’t know the answer I won’t know the answer until I know! Right? Has any vendor considered attempting to approach the problem of small physician practices adoption with a system that a larger group, say a co-op or a consortuim, could purchase?”

    There have been a number of attempts at doing just that while staying on the right side of Stark. VHA had a product they endorsed and sold. The volume purchase agreement gave some relief to the high cost problem but ultimately it didn’t work — for the reasons well noted here here in HIS Talk.

    There were some associations (MSO) that were put together in order to help physicians negotiate better reimbursement (as a group rather than individually) but again the competition issues cause many small practices to turn away from that avenue.

    The VA has product that can be licensed for free (software) but still requires implementation, hardware and support. Still costly.

    Insurance companies have gotten on board (Blue Cross is a good example) to sell EHRs to their physicians. But, docs are suspicious of any “help” payors may offer.

    Now that Stark has been relaxed a little hospitals are getting into the game and offering to give some discounts to EHRs . The most innovative project I’ve seen to date (seen as in I was working with the docs – hot hearing about it) has been a big discount on software and direct support by the hospital rather than phone support. The practice that I work with now basically has it’s IT run by the local hospital. Their in a MOB literally next door to the hospital and all the practice needed to do was invest in some software.

    Several companies that market to small practices fooled around with ways of reducing the costs for the implementation process by handling the implementation remotely and using web-based training, remote support for upgradses and using technology such as Webex to help users when they had problems. Ultimately those projects didn’t work well and the companies saw a pretty hard hit to earnings (profitability).

    Lots of attempts — lots of hesitation by physicians. They’ve been so hardily pounded on for cost reductions and quality increases a lot of them are wary just because they are sure they are going to get sucked into some kind of bad business deal. They are also worried that if they invest in a product they’ll see another payment reduction by Medicare (such as the recent 5%) that they won’t be able to keep the doors open for lack of cash.

    The best solution seems to be some kind of government support for purchasing and maintaining EHRs. It’s been proposed many, many times but is getting little traction. Seems to me if we can bail out Wall Street we could throw a little money to some docs. Especially the small ones. If the government is so interested in cost reductions and increases in quality lets see some support for the small guys.

  22. Johnny Smooth has it right

    “It will be imperative that doctors move to a digital modality as their customers will increasingly expect such out of them.”
    Consumers want access to their info online, hence PHR. If the doc isn’t going to make it easy to access, they will go to someone who will, Privacy concerns? HA! Facebook, Youtube, Twitter – Doesn’t look like there’s too much concern about privacy.

    “What the real focus needs to be is on value delivered and the value proposition … and what type of customers that practice intends to serve.”
    Right- the next generation of healthcare consumer wants a relationship based on information that’s easily accessible. Paper just won’t cut it.

    And here’s a survey that shows a bit of hope coming with the new set of med school grads:
    “Sixty-two percent of medical students said having an electronic health record system at the place they choose to practice is very important, according to a survey by Epocrates. Twenty-eight percent of medical students surveyed said EHR availability was important in choosing a practice, while 8% said it was somewhat important. Only two percent of respondents said EHR availability was not important in choosing a future practice. ”

    Hopefully we can get to them before they experience too much EMR cynicism/skeptism from the older docs.

    Emotion is exactly where we need to go. Forget ROI, better customer/patient relations is where the value is. The satified patient refers their family and friends leading to a growing practice.

    The question to answer is not, ‘What’s my ROI” it’s “How will it build my practice.”

    Yes, it’s a bit more intangible, but the good sales rep can do it.

  23. Good comments so far.

    One factor that I believe plays a role in the low pace of installation of EHRs, and the underutilization of EHRs once installed, is, quite simply, inertia.

    As a practicing physician having used two different EHRs over 10+ years of practice, I can say definitively that a good EHR can help a physician be more efficient, improve clinical quality, and improve patient satisfaction. There are a LOT of docs who (like me) would never want to go back to paper.

    However, it’s an unavoidable reality that the initial adoption for every physician involves a temporary period of lower efficiency and substantial frustration. As EHRs evolve in usability, reliability, and ease of installation and configuration, this will lessen, but it will never disappear. You have to trudge uphill for a while before you can coast downhill, far beyond where you started.

    And for most human beings, it’s REALLY hard to make that uphill trudge, even if you believe that the other side is better than where you are now. It’s one of the oddities of human psychology, but one which you can see all around you every day in 1,000 different ways.

    So the diffusion of EHR technology is not like the diffusion of fax machines or cell phones. Maybe it’s more like the transition of America from a society where nearly everyone smokes to one where non-smoking is the norm. As with smoking, EHR adoption will occur from a combination of the gradual accrual of doctors who have never known any other way (like kids who never smoked), attrition of those who have never used an EHR (like the gradual disappearance of smokers), and the hard-as-heck efforts of those who have gone from using paper to using EHRs (like folks who have made the switch from smoking to being smoke-free).

  24. Usual comments that one reads about why EMR adoption rates are so low. The comment by the EMR vendor employee regarding the failed implementations is the only one reason not to procees with implementation with any real substance. Although bad software will cause failure, the reasons for failure are rarely due to bad software given the large number of good to excellent systems out there.

    Athenahealth is simply one more purveyor of contracted-out billing and collector of billings. It is not surprising that Mr. Bush cannot explain the economics of investing in EMR systems. His business simply absorbs at a ridiculously high cost to his customers the hassle of dealing with obtaining payment. Athenahealth has at its disposal the entire revenue stream from which it skims its fee. Not a task that requires much knowledge about much of anything.

  25. I do not condone publicly demeaning another persons work especially when it is done on the internet. or in print.

    I do have to say that Mike Gleason, put forth a very enlightening and engaging peace. And I drew more from that one piece then the entire conversation that went along with this article..

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