Curbside Consult with Dr. Jayne 4/21/14

Next weekend is my medical school reunion. Although I can’t make it, the fact that it is happening spurred me to try to re-connect with old friends and colleagues. Some are from med school, others are from residency, and a few are friends I made when I was a young solo practice doc trying to figure out how to fit into the medical establishment.

I had a nice chat with a friend of mine who is a pediatrician. It was interesting to catch up because her practice is different from what I see every day. Hers is a traditional group private practice, but they only take commercial payers – no state or federal programs. As such, they’re not on the Meaningful Use treadmill. They document in paper charts that are filed by family rather than individual – totally old school as far as most health information management folks are concerned.

I had talked to her several years ago when they were trying to implement the same EHR that we were rolling out to our employed physicians. They had purchased their system through a local reseller, hoping to get good service from people close to home rather than buying directly from our vendor who is headquartered halfway across the country.

Unfortunately that local reseller was purchased by another reseller who didn’t have the greatest track record for customer service and most of their local resources were let go or quit. Because of that situation (coupled with turnover in their practice leadership), they had halted their implementation after bringing the billing system live.

They were heavy admitters to one of our hospitals, so I did a courtesy consultation to provide some advice on how to proceed. I talked to them about working with their reseller to come up with a phased implementation plan that would help them transition slowly since they weren’t in a huge hurry and had multiple older physicians who would need convincing and a lot of hand-holding.

We had run into each other in the newborn nursery almost a year after that, so I knew they continued to struggle with the system and ultimately went back to paper, although they were doing well with the billing system.

When I caught up with her a few weeks ago, I learned that they had made the decision to replace their entire system. They never got the EHR off the ground, largely because the older physicians perceived the software as too complicated and too clicky. They had not taken any upgrades since their initial installation in 2009, so I can see why they thought that – early versions of the software were indeed clicky and it wasn’t easy to save physician-specific defaults and preferences.

The practice had tried to re-implement on that version even though our vendor had since rolled out a redesigned user interface that vastly improved the workflow. She said that due to a lack of confidence in the reseller coupled with the physician resistance, they were afraid to take any upgrades.

They decided to go with a specialty-specific product, rolling out the practice management system first without any kind of conversion from their previous system. For a busy practice with nearly a dozen physicians, that surprised me – not even a demographic conversion. They went live on April 1 and every patient had to be re-registered, whether they were presenting for an appointment or calling in.

They made no adjustments to the schedule to accommodate the change because the providers refused to risk a revenue loss. As a result, they are running hours behind by the end of every day. Talk about an April Fool’s Day joke! Needless to say, no one is happy – the providers, the staff, or the patients.

Patients are complaining about the registration process because they have to provide information they didn’t previously, specifically race, ethnicity, and preferred method of contact for patient reminders. Sounds familiar! I asked her why they’re doing that since they’re not attesting for MU, don’t participate in any research or quality programs where those fields are needed, don’t do email or texting, and it’s not required by payers in our area (yet). The answer: those fields are required in the system and can’t be turned off.

I asked her how the system handles other information that may be needed for MU but not for the way the practice currently delivers care. She has no idea. I wouldn’t be surprised if there are plenty of other required fields that they’re not going to be happy about once they start implementing EHR.

I asked what their plans are for that. She didn’t really know whether they plan to implement EHR in 60 days, 90 days, or a year. There’s no burning platform, but I would expect a partner to at least have some kind of understanding of the group’s strategic plan. I asked about the family charting – which is very different from individual charting – and she had no idea how they plan to resolve that, either.

I’m sure I was giving her some funny looks during this discussion because my brain was positively spinning. They’ve traded one system (where at least they could have turned off those required fields) for another with no long-term plan for whether they’re simply converting to paperless charts or whether they plan to use an electronic health record to transform care.

I suspect that as time passes they’ll find themselves in substantially the same position they were in six months or a year ago, except they’ll be paying down another initial investment. I didn’t ask about the cost of the new system, but I hope that at least their monthly software maintenance payments are a little less. Until they start having some serious conversations with all the physicians though about what having an EHR means to them, what they want to get out of it, and how they plan to go about it, there is the potential for some serious unhappiness down the road. They’ll be doing the same dance but with another vendor.

Although they were never stressing about Meaningful Use, they were having mild heart failure over ICD-10 and were very grateful for the recent reprieve. As a relatively small single-specialty group, their transition will be less complicated (and hopefully less arduous) than some of ours and I wish them well. Given their payer mix and patient population, some of their challenges are different from those faced by my practices on a day-to-day basis, but many are the same. I left her with some good discussion points for her next practice management meeting and a promise to check in more frequently to see how they’re doing.

There are a fair number of physicians and practices in the market for replacement systems. I wonder what percentage of those purchases are truly from system deficiencies (including lack of certification)? I’d like to compare that to what fraction of them are due to a lack of understanding around how to successfully transition to electronic health records coupled with a vendor who is unable/unwilling to take a hard stance with its customers to force them to do things in a manner that will make them successful.

Are you in the market for a replacement system? What makes you think it will be different the second time around? How are you planning to do things differently? Email me.

Email Dr. Jayne.