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EMR: One Size Does Not Fit All
By Evan Steele
A recent comment on HIStalk, by a hospital CIO about what he identified as the best EMRs for enterprise systems and their physicians, highlights a problematic and all-too-prevalent misconception. The fact is, it is impossible to satisfy both hospitals and community ambulatory physicians with the same EMR product. Furthermore, even the ambulatory market cannot be looked at as a whole. EMRs designed for primary-care physicians respond to a set of needs that are very different from those of specialists.
Enterprise EMRs simply do not work in high-volume ambulatory practices. This is particularly true for specialists’ practices. Many hospitals have had some success with Epic and other hospital-focused EMRs, but success has been limited when these same hospitals ask physicians — again, particularly the specialists — to implement these systems in their practices. A monolithic enterprise product cannot possibly support equally well such different workflows, patient care scenarios, and providers’ needs.
Within the ambulatory market itself, it is time to bifurcate the EMR discussion into two groups: EMRs for primary care physicians and those for specialists.
Industry analysts typically lump all EMRs into one category, which does not adequately differentiate the market segments or their distinct needs. The major EMR vendors have massive footprints in the marketplace, yet a small company like SRSsoft has the lion’s share of referenceable high-volume, prominent specialty practices in areas like orthopaedics and ophthalmology. Why? Because one size does not fit all, and it is impossible to satisfy the needs of both groups without compromising the needs of one.
The American Academy of Orthopaedic Surgeons (AAOS) acknowledged this issue in its recently released EMR Position Statement, pointing out that “Many systems are geared toward primary care medical practice, which can limit the utility of EHRs for specialty surgical practice.” It correctly suggests that “the different needs and uses of EHR by disparate medical specialties should be recognized.”
Specialists represent approximately 50% of the physician market, a sizeable segment that is largely being ignored. How are specialists to determine which EMRs are designed for their needs?
KLAS, the closest our industry has to a JD Powers–type of rating source, does not break out its ratings by specialty. This means that if an EMR vendor does well in the ambulatory primary care market and has high KLAS ratings, an unsuspecting specialty practice might purchase their product based on those ratings, only to find out that the product does not fit their unique needs.
Exacerbating the situation is the fact that KLAS only surveys practices that have actually installed the EMRs. It does not survey practices with failed implementations. Since specialists represent a disproportionate number of the failures, the information is even further biased.
The result is that there are thousands of specialists who purchase EMRs from highly rated and/or household name vendors, but who end up with failed implementations and significant financial loss.
One size does not fit all. There are good EMR solutions available for every type of physician. It is incumbent upon the individual physician to research and identify the product that best suits his/her practice’s needs.
Evan Steele is CEO of SRSsoft of Montvale, NJ.
ClickFreeMD Comment Response
By Bob Gordon
Note: Mr. H here. I’m breaking my “no commercial pitch” rule this one time because Inga had questioned the business model of ClickFreeMD, which offers practice systems including billing for a flat monthly fee rather than the traditional model of a percentage of collections. Inga’s point was that the percentage model encourages the billing company to collect. CEO Bob Gordon was nice enough to e-mail Inga an explanation and we thought his response might interest some readers even though it is hardly unbiased. I’m not endorsing their product and I have no connection to ClickFreeMD.
ClickFreeMD leapfrogs the percentage-based provider business model. Consider the following:
- No start-up, implementation or training charges.
- The flat fee is lower on an equivalent percentage basis than most practices would pay for outsource medical billing alone and far less than in-source options.
- If the practice improves its revenue or we boost it (which we often can do), the equivalent percentage drops through the floor.
- The breadth, quality, and integrated end-to-end nature of our software, services, and support are unrivaled. Physicians are paying twice as much elsewhere for much less elegant solutions today.
- The flat fee sticks. If encounter or charge values increase, the flat fee stays the same and the practice captures cost free revenue. If it drops outside ordinary seasonality range, the rate is adjusted down pro-rata so our physicians’ earning power is fully protected.
- Importantly, the flat fee is backed by a performance guarantee that makes sure we work every claim or we rebate half of the flat fee. There is no equivalent protection in a percentage-based model. In fact, any claim that takes more than 15 minutes to resolve in a percentage system is probably costing them more than they are making, and hence billing company profitability is at some point in the collection continuum inversely correlated to increasing practice collections.
- Our contracts all have 90-day outs and low price match guarantees for comparable services.
You may ask how we do this. We have deep domain expertise from running billing companies, back offices, and technology companies for decades and have organized a Southwest Air-like discount fee, high-result business model that is very scalable. We expect that ongoing volume will feed a virtuous cycle for all, continuing to allow us to offer more for less while achieving top results.
One of the most striking things we are doing is the least recognized — giving the practice their flat-fee price, online and instantly, as well as their included services, without asking them to give us any information. Try this anywhere else like Athena and what we do in 30 seconds becomes a multi-day process that involves e-mail / telephone / online discussions and/or meetings and requires the practice undressing for the vendor. We are completely ONE-WAY transparent. That’s because we want the practice to decide if they want to contact us — after they are satisfied that this is a superior value for them and only then. We aren’t interested in lead nurturing them to death.
This is about "more dollars for doctors" and great news in the group practice fight to sustain their independence. We are doing our part to create a reversal of fortune in the group practice community with a unique business model that raises revenues faster than costs, delivers immediate and ongoing savings, and provides the tools and support that allow them to be ready for tomorrow.
Like the boiled frogs of lore, physicians have been nickel and dimed by payers, billing companies, and others, overpaying to under-produce for so long, they find themselves working much, much harder for less and less. We’re changing that and we’re passionate about it! Thank you for your consideration.
Bob Gordon is CEO of Click4Free of Chevy Chase, MD.
It’s Official: The Rush for Talent Has Begun
By Tiffany Crenshaw
In recent weeks, a number of existing and prospective clients have called me for a pulse on the healthcare IT recruitment marketplace and thoughts on how to attract quality resources. After a number of such calls, I decided to put my thoughts in writing and share.
Let’s start with the good news. Industry hiring is definitely picking up and employed candidates are now less afraid to make a career change then they were three to six months ago.
As for hot products, it’s no secret that Epic is hot, hot, hot. Hospitals are purchasing Epic left and right. Honestly, there are simply not enough Epic resources, especially Epic-certified resources, to go around, so the talent war is raging. Cerner recruitment remains modest but steady, while McKesson needs are starting to rebound after quite a lull.
In the ambulatory market, we are seeing more and more requests for eClinicalWorks and Allscripts. New names like Sage and Greenway are coming to light. And occasional needs for Meditech, Siemens, IDX/GE and Eclipsys are surfacing.
On the integration side, Cloverleaf and e-Gate skills are still in demand, but we are seeing more requests for Web-based and lesser known products like Ensemble, Symphony, and Rhapsody.
The hiring demand is highest by far for hands-on resources to design, build, and install EMR applications. However, there is a fair amount of activity for sales, project management, and training professionals, including go-live support.
CPOE, clin doc, pharmacy, oncology, and HIM are generating the most recruitment activity within the applications. Based on new client requests, we foresee growing needs for business intelligence, security, and report-writing resources.
In addition to employers’ desire for one or more of the skill sets mentioned above, most are adding clinical designation to the requirements. Over 50% of our job requisitions right now require clinicians. Pharmacists, nurses, and physicians with healthcare IT experience are in great demand.
However, post-recession hiring is creating challenges previously unheard of in my 12-year history recruiting in this industry. The process is now wrought with excruciatingly slow interview scheduling, shrinking employee benefits packages, little to no relocation assistance, and financially conservative offers resulting in more and more frustrated candidates.
Things have changed drastically since the lowest points of the recession. After the release of Meaningful Use requirements, recruiting mania has taken off. Everyone seems to have hiring needs. Candidates are getting called left and right by internal and external recruiters. Just check out a few of the job boards if you don’t believe me — you’ll see countless job postings. Furthermore, check out all of the recruiting firms with no previous healthcare IT experience trying to break into this market as experts claim abundant need for resources.
If your organization is currently or will be in the market soon for these in-demand resources, you may want to evaluate your hiring process, recognize that your competition is fierce, and take note of a few trends our candidates and clients have shared with us quite candidly over recent months.
- New car syndrome. Candidates are migrating to new implementations. Who can blame them? It’s more exciting to be on the ground level and see a project through from A to Z.
- Red carpet treatment. Employers who roll out the red carpet win. When weighing decisions between job offers, candidates almost always choose the employer who provided quickest response time and showed sincere interest in them. (Both response time and sincerity are simple and no-cost ways to roll out that red carpet.)
- Relocation blues. Relocation is a HUGE issue right now. Even if candidates want to move, they can’t do so because of the housing market. Kudos to all of the organizations willing to work around this by providing remote work, commuting, or coverage of interim living expenses.
- Communicate. Many, many candidates are feeling jerked around by potential employers because of lack of communication in the interview process. Here’s what they are thinking: “If I don’t feel valued as a candidate, how are they going to treat me as an employee?” On the flip side, these candidates are communicating with plenty of their peers. Too many hospitals and consulting firms are getting bad reputations as being lousy places to interview and to work.
- Too much is not always a good thing. In the quest for resources, too many organizations are panicking and calling in all of the troops — internal recruiters, employee recruiting bonuses, dozens of external recruiters and advertisements. Candidates get called multiple times by different sources all looking to fill the same positions. Not only do they end up confused, but all the activity makes candidates suspicious. They wonder what’s wrong with an organization that has such a hard time attracting and retaining talent?
- Get on board. We are hearing more and more horror stories about candidates showing up on the first day only to find their new employer is not ready for them. This gets them off to a bad start from the get-go. Employees stay longer and perform better when they feel welcomed and the transition process is smooth. The period of time between offer acceptance and start date can also be a black hole, when candidates are most vulnerable. Employers are losing candidates this far into the game because they aren’t communicating with them. If you don’t have a formal on-boarding program, now is probably a good time to look into it.
- Disconnect between human resources and hiring managers. As an outside firm, we work with both HR representatives and hiring managers. We hear complaints on both sides about the other on a regular basis — namely due to lack of response. The hiring managers want candidates fast. And HR wants answers fast. Throw candidates in the mix who get frustrated as well and it’s a nasty situation. However, we find that employers who really engage the final decision-maker in the process from beginning to end and set response expectations up front have the least amount of frustrations and the most successful outcomes.
In summary, you can safely say that the industry is quickly changing to a candidate-driven market and that the market is impacted heavily by post-recession recovery and Meaningful Use. It is official. The rush for talent really has begun.
Tiffany Crenshaw is president and CEO of Intellect Resources of Greensboro, NC.
The Coming Speed Bump in the EMR Market
By Jon Shoemaker
It’s no secret that there is currently a mad rush occurring, not unlike The Oklahoma Land Rush of the 1800s, where hundreds of companies both new and old are getting into the business of healthcare information technology. Some come with industry expertise. Others come to take advantage of the financial opportunity. Consider Best Buy, the consumer electronics giant, that will install your EMR using their Geek Squad. So much for needing clinical expertise!
I believe this climate of frenetic activity will cause the EMR market to encounter a large, steep speed bump in the next 10 years. It won’t be from all of the EMR installations or supporting all of these systems, as this will create thousands of jobs and supporting infrastructure that currently does not exist. The bump in the road will come when all of these new digital silos must talk to each other as required in Phase II of Meaningful Use (MU). It is the very selling point of these systems — simple communication and usability — which become the Achilles heel of these EMRs.
EMR’s to date are not installed with a common code structure for identifying exams, studies, or services, all of which will need to be exchanged outside of the office in Phase II of MU. The reason for this lack of standardization has nothing to do with EMR functionality or capability — it is that everyone is still thinking locally not globally.
To ensure true interoperability and exchange of patient health information, EMRs must be installed to satisfy the local requirements, but also with the forethought that they will integrate to larger systems. This requires standards and standardization. The absence of a standard will require the use of translation services so that HIE repositories use the same codes for exams performed across the region.
Translation services, while a viable alternative to standardization, require one-off knowledge for the database structure and logic for each customized local EMR as well as that of the destination repository. This level of granularity creates layers of complexity for maintenance and mapping. Any changes to local system will mandate updates to the translation engine. The support nightmare of constant mapping modifications to assure the proper codes are sent outbound or received inbound will be effectively unsustainable.
Once all of the paper silos are replaced by digital silos, there will be enlightenment of EMRs that were installed incorrectly, don’t address the clinical workflows of the office, and don’t communicate outside of the office with a standard communication protocol using standard coding methods. This will lead to a second phase of the EMR revolution will include translation services and reinstallation of EMRs to address workflow and data gaps. This will have to be resolved before integration to a larger HIE repository can take place.
If we begin now with standardization of workflow and codes and ensure they are addressed with current EMR installations, we will be in a better place in five years and users will see the true benefits of these systems. With our current strategy of “every man for himself,” we risk losing users’ confidence once these systems are installed and address workflow and physician concerns. Once we lose the users’ confidence, they will stop using the system and re-adoption efforts will prove Herculean.
As you begin planning your EMR implementation, there are hundreds of questions to ask. When it comes to meeting the long-term requirements of MU as well as realization of the true benefits of an EMR, here are a few to begin with:
- Have we reviewed and documented our office workflow?
- Are we using the new SNOMED codes?
- Are we following standardized codes for services rendered?
- Does the installation team understand clinical workflow or do they look glassy-eyed when we discuss medical terms?
- Is our vendor of choice an IT company trying to cash in on the HIT initiative without clinical experience and knowledge which could place our business at risk?
- How will this EMR connect us in the future to larger integrated systems?
Jon Shoemaker is senior consultant with Ascendian Healthcare Consulting of Sacramento, CA.